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CANCER  OF  THE  STOMACH 


A     CLINICAL     STUDY     OF     921     OPERATIVELY 
AND  PATHOLOGICALLY  DEMONSTRATED  CASES 


/  ) 


BY 

FRANK  SMITHIES,  M.  D. 

Gastro-enterologist  to  Augustana  Hospital,    Chicago;   formerly    Gastro-enter- 

ologist  to  The  Mayo  Clinic,  Rochester,  Minn.;  formerly  Instructor  in 

Internal   Medicine   and   Demonstrator  of  Clinical  Medicine  in 

the  University  of   Michigan,  Ann    Arbor;  Fellow  of  the 

American   Gastro-enterological  Association,  Etc. 


With  a  Chapter  on  the 

SURGICAL  TREATMENT  OF   GASTRIC 
CANCER 

BY 

ALBERT  J.  OCHSNER,  M.  D.,  LL.  D.,  F.  R.  C.  S. 

Professor  of  Clinical  Surgery  in  the  School  of  Medicine  of  the   University   of 
Illinois;  Surgeon-in-Chief  to  Augustana   Hospital,    Chicago;   Con- 
sulting Surgeon  to  St.  Mary's  Hospital,  Chicago 


ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS   COMPANY 

191  6 


Copyriglit,  1916,  bj'  ^Y.  B.  Saunders  Company 


Printed  in  America 


TO   MY 

FIRST   TEACHER  IN   MEDICINE 

DR.  GEORGE  DOCK 

AND 

MY  FRIENDS 

DRS.  JAMES  B.  HERRICK,  RICHARD  DEWEY, 

IRA  DEAN  LOREE 

AND 

WARREN  PLIMPTON  LOMBARD 


PREFACE 


This  work  attempts  to  set  forth  the  facts  which  are 
considered  valuable  from  a  study  of  921  operatively  and 
pathologically  demonstrated  instances  of  gastric  cancer. 

The  cases  and  their  records  comprised  part  of  my 
services,  extending  over  ten  years,  at  the  University 
Hospital  (Ann  Arbor,  Mich.),  the  Mayo  Clinic  (Rochester, 
Minn.),  and  my  present  clinic  at  Augustana  Hospital. 

It  is  at  least  a  decade  since  a  monograph  upon  this 
subject  appeared.  The  interim  has  been  prolific  in  its  con- 
tributions to  our  better  clinical,  pathologic  and  surgical 
knowledge  of  gastric  cancer.  It  is  to  be  hoped  that  the 
practical  worth  of  the  more  important  of  these  advances  is 
sufficiently  emphasized  in  the  pages  following. 

For  numerous  courtesies,  I  am  indebted  to  many.  Par- 
ticularly would  I  express  my  gratitude  to  Drs.  William  J. 
Mayo,  Christopher  Graham,  William  Carpenter  MacCarty 
and  Russell  D.  Carman  of  the  Mayo  Clinic,  for  permission 
to  study  cases  and  records,  and  for  illustrations  and  material 
in  the  text.  Dr.  Frederick  Hoffman,  statistician  of  the 
Prudential  Life  Insurance  Company,  has  generously  al- 
lowed me  to  avail  myself  of  the  results  of  his  valuable 
compilations.  Dr.  Albert  J.  Ochsner  has  kindly  written 
the  chapter  entitled  ''The  Surgical  Treatment  of  Gastric 
Cancer."  It  has  been  ably  illustrated  from  sketches  made 
at  the  operating-table  by  Mr.  Thomas  Jones.  Drs.  Oscar 
Nadeau  and  John  Nuzum  and  Mr.  E.  Schmidt  have  helped 
with  the  illustrations  and  the  text.  My  secretaries,  Misses 
Pearl  Empey  and  Frances  Horgan,  have  been  most  faithful 
and  painstaking.  From  my  wife,  I  gladly  acknowledge 
much  practical  aid  and  encouragement. 

13 


14  PREFACE 

Finally,  it  should  be  understood  that  this  monograph  has 
been  written  during  a  moderately  busy  life.  It  is  by  no 
means  the  ''last  word"  upon  gastric  cancer.  It  is  simply 
one  clinician's  analysis  of  certain  facts  which  he  observed 
in  a  great  group  of  patients  affected  with  a  like  ailment. 

Frank  Smithies. 

Chicago,  Illinois, 
January,  1916. 


CONTENTS 


CHAPTER  I 

Page 

General  Distribtjtion  axd  Etiology 17 

CHAPTER  II 
Morbid  Anatomy:  Gross,  IMicroscopic  and  Experimental   ....     51 

CHAPTER  III 
Symptomatology 110 

CHAPTER  IV 
Physical  Abnormalities 160 

CHAPTER  V 
Examination  of  Gastro-intestinal  Function 193 

CHAPTER  VI 
Roentgen  Exaihnation  in  Gastric  Cancer '   .    .  268 

CHAPTER  VII 
The  Blood  in  Gastric  Cancer 319 

CHAPTER  VIII 

The   Significance  of  Gastric  Ulcer  with  Respect  to   Gastric 

Cancer 350 

CHAPTER  IX 
Gastric  Cancer  in  the  Young 373 

CHAPTER  X 

Differential  Diagnosis 38,2 

15 


16  CONTENTS 

CHAPTER  XI 

Page 

Surgical  Treatment 417 

Bt  Albert  J.  Ochsner,  M.  D.,  LL.  D.,  F.  R.  C.  S. 

CHAPTER  XII 
Nox-suRGiCAL,  Treatment 472 

Index  op  Names 501 

Index 505 


CANCER  OF  THE  STOMACH 


CHAPTER  I 
GENERAL  DISTRIBUTION  AND  ETIOLOGY 

Definition. — Gastric  cancer  is  a  disease  of  the  stomach 
produced  by  the  development  of  a  neoplasm  in  the  wall 
of  that  \T-Scus.  The  affection  is  generally  of  a  perniciously 
progressive  natm'e,  and  occurs  with  the  greatest  fre- 
quency between  the  ages  of  40  and  70  years.  Fatal 
termination  is  the  rule.  The  disease  is  characterized 
clinically  b}^  imperfect  gastric  function.  This  malfunction 
usually  manifests  itself  b}^  abdominal  distress  or  pain, 
associated  with  loss  of  appetite  and  body  weight,  by 
weakness,  anemia,  cachexia,  vomiting  and  the  appearance 
of  an  epigastric  tumor. 

The  gastric  extracts  or  the  vomitus  frequently  exhibit 
deficient  gastric  empt^-ing  power,  diminished  free  hydro- 
chloric acid,  altered  blood  and  the  presence  of  foreign 
organic  acids,  microorganisms  and  ferments. 

When  the  stomach  is  filled  with  substances  opaque  to 
the  Roentgen  t&j,  alterations  from  the  normal  contour  can, 
not  infrequently,  be  demonstrated  upon  examination  with 
the  fluoroscopic  screen  or  the  x-ray  plate. 

Frequency  of  Cancer  in  General. — Trustworthy  statistics 
record  that  more  than  75,000  deaths  from  cancer  occurred 
in  the  United  States  during  1913.  It  is  estimated  that 
there  were  fully  a  half  million  deaths  from  malignant 
disease  in  the  same  period  throughout  the  civilized  world. 
Of  the  cancer  deaths  recorded  in  the  United  States  Regis- 

2  17 


18 


CANCER    OF    THE    STOMACH 


tration  Ai'ea  theii-  ratio  to  deaths  from  all  other  causes  in 
1911  was  as  1  :  19.06.  The  differences  in  ratio  geographic- 
ally are  demonstrated  in  Table  1. 

Table  1 

T-v. 

State 


Michigan 

Vermont 

Wisconsin 

Wasliington . . . . 

Minnesota 

ISIaiae 

Massachusetts . 

CaJif  omia 

Ohio 

Rhode  Island . . 

New  York 

Indiana 

New  Jersey .... 
Connecticut . . . . 
Pennsylvania .  . 

Utah 

Maryland 

Colorado 

North  Carolina . 
Kentuckv 


Deaths,  all 
causes 

Cancer  deaths     i 

Cancer  ratio 

37,993 

2,137 

1:13. 05 

5,440 

396 

1:13.98 

26,987 

1,841 

1:14.65 

10,187 

679 

1:15.002 

21.988 

1,423 

1:15.24 

12.031 

738 

1:16.3 

53.003 

3.262 

1:16.55 

34,010 

2.053 

1:16.56 

65.466 

3,936 

1:16.63 

8.644 

510 

1:16.94 

142,608 

8,209 

1:17.37 

35.210 

1,943 

1:18.1 

37,779 

2,054 

1:18.39 

17,552 

895 

1:19.5 

111,842 

5,426 

1:20.61 

3,913 

188 

1:20.81 

20.694 

955 

1:21.5 

10.740 

459          , 

1:23.3 

6,672 

219          1 

1:30.46 

30,407 

986 

1:40.8 

Ratio  of  Cancer  Deaths  to  deaths  from  all  other  causes  in  United  States 
Registration  Area  in  1911. 

It  is  seen  that  7  of  the  then  registration  states  fell  be- 
low the  general  average,  while  13  states  rose  above  such. 
The  striking  difference  in  ratio  between  cancer  deaths  in 
Michigan  from  those  in  Xorth  Carolina  and  Kentucky 
(more  than  3  times  the  minimum)  would  seem  to  point 
to  either  errors  in  diagnosis  or  local  increase  from  unsolved 
cause  in  the  states  evidencing  the  maximum. 

Coniparison  between  the  ratio  of  cancer  deaths  in  the 
United  States  and  foreign  countries  is  estimated  on  the 
same  basis  of  mortahty  returns  in  Table  2  modified  from 
Budav. 


GENERAL   DISTRIBUTION   AND    ETIOLOGY 

Table  2 


19 


Country 


Ratio 


Country 


Ratio 


BrazH. (1908)!  0.41 

Portugal (1904)  2.39 

Spain (1903)  4.4 

Japan (1905)  5.3 

Belgium (1907)  6.02 

Victoria.! (1907)'  6.09 

Italy (1906)  6.09 

Hungary (1904)  7.00 

Germany (1907),  7.45 

Austria (1905)^  7.5 


U.  S.  A (1908) 

England (1907) 

New  Zealand ....  (1907) 

Norway (1906) 

Holland (1903) 

Sweden. .  .  .  (1890-1898) 

France (1906) 

Denmark (1907) 

Switzerland (1907) 


7.65 

9.08 

9.3 

9.75 

9.9 

9.96 

10.00 

12.2 

12.5 


Comparison  between  ratio  of  Cancer  Deaths  in  the  United  States  and 
in  other  countries.- 


Wide  variations  in  cancer  death  ratio  are  shown.  These 
cannot  be  explained  wholly  upon  the  theory  of  inefficient 
government  mortality  records  or  unproved  diagnoses. 


Table  3 


Age  period 

1911 

1901 

all  ages 

Persons       Males 

Females 

Persons 

Males 

Females 

Crude  rate 

83.9 

77.6 

3.0 

1.2 

1.3 

2.3 

4.8 

13.9 

61.0 

166.3 

352.4 

566.7 

794.7 

155.7 
159.0 

64.2 

56.7 

3.1 

1.3 

1.0 

2.9 

4.9 

9.7 

31.1 

109.2 

283.4 

512.8 

730.5 

117.7 
117.9 

104.0 

97.2 

3.0 

1.1 

1.5 

1.7 

4.6 

19.4 

92.5 

227.0 

422.3 

617.8 

848.7 

195.0 
195.9 

65.8 

62.2 

3.4 

1.0 

0.9 

2.1 

3.9 

13.4 

60.2 

146.5 

268.3 

418.8 

557.6 

124.5 
127.2 

48.7 

43.6 

3.8 

1.3 

0.9 

1.9 

3.3 

9.4 

32.5 

90.0 

203.8 

366.0 

520.8 

90.9 
90.4 

83.0 

Corrected  rate 

79.7 

Under  5  years 

3.1 

5  to  9  years 

10  to  14  years 

0.8 
0.9 

15  to  19  years 

2.2 

20  to  24  years 

4.5 

25  to  34  years 

17.5 

35  to  44  years 

89,6 

45  to  54  years 

205.4 

55  to  64  years 

331.8 

65  to  74  years 

468.9 

75  years  and  over 

25  years  and  over : 
Crude  rate 

589.8 
158.7 

Corrected  rate 

160.3 

Mortality  from  Cancer  in  the  United  States,  1901-1911.     (Registration 
States  of  1900;  Rates  per  100,000  of  Population  by  Age  and  Sex.) 


20 


CAXCER    OF    THE    STOMACH 


Increase  in  Cancer  in  General. — For  much  of  our 
accurate  knowledge  that  such  increase  is  real  and  not 
apparent  we  are  indebted  to  Hoffman.  That  this  is  so 
for  the  United  States  is  exhibited  in  Table  3,  compiled  from 
the  publications  of  the  Department  of  Commerce.  The  in- 
crease is  plotted  for  each  set  in  Charts  I  and  II  (page  21). 

Emphasis  is  to  be  placed  upon  the  fact  that  there  has 
been  an  actual  increase  in  general  cancer  mortality  rate 
in  all  decades  above  age  40.  Hoffman  has  computed, 
from  an  enormous  experience,  that  in  the  United  States 
the  number  d}dng  from  cancer  at  the  present  time  is 
approximately  25  per  cent,  greater  than  10  years  ago.  He 
finds  that  of  the  total  mortahty  from  cancer  in  the  regis- 


Tahle  4 
(Rates  per  100,000  Population) 


1900 


1909 


Actual 
increase 


Per  cent,  of 
increase 


Switzerland 

Netherlands 

Scotland 

England  and  Wales. 

Norwaj^ 

German  Empire 

Ireland 

Austria 

New  Zealand 

Australia 

Japan 

Italy 

Denmark 

Spain 

Hungary'' 

Jamaica 

Serbia 

Ceylon 


129.9 
91.7 
79.0 
82.9 
90. S 
72.1 
60.8 
70.9 
56.3 
62.6 
45.4 
52.2 
46.2 
39.3 
36.7 
16.5 
9.4 
6.6 


126.7 
102.6 
101.6 
96.1 
94.6 
83.5 
SO.O 
78.6 
73.2 
72.3 
65.2 
63.5 
56.1 
51.0 
44.5 
18.3 
12.61 
4.0 


3.22 

10.9 

22.6 

13.2 

3.8 

11.4 

19.2 

7.7 

16.9 

9.7 

19.8 

11.3 

9.9 

11.7 

7.8 

1.8 

3.2 

2.6^ 


2.52 
11.9 
28.6 
15.9 

4.2 
15.8 
31.6 
10.9 
30.0 
15.5 
43.6 
21.6 
21.4 
29.8 
21.3 
10.9 
34.0 
39.42 


Average 


59.6 


73.5 


13.9 


23.3 


1908.     -  Decrease. 

International  Cancer  Statistics,  1900-1909. 


GENERAL   DISTRIBUTION   AND   ETIOLOGY 


21 


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22 


CANCER   OF   THE    STOMACH 


tration  area  during  1906  to  1910,  the  proportion  of  such 
deaths  at  the  age  of  45  and  over  was  83  per  cent. 

In  countries  other  than  the  United  States  this  increase 
in  cancer  mortality  practically  is  a  constant  finding,  as 
shown  by  Table  4. 

The  relative  increase  in  Germany,  England  and  America 
is  demonstrated  graphically  in  Chart  III.  These  statistics 
return  the  significant  information  that  'Hhe  cancer  death 
rate  in  the  civilized  portion  of  the  earth  has  increased  23.3 
per  cent,  in  the  past  decade." 

In  Gastric  Cancer,  the  ratio  of  occurrence  to  that  of 
non-cancerous  disease  is  to  be  determined  mainly  from 
the  study  of  hospital  admissions  and  mortality  records. 
Information  obtained  from  examination  of  hospital  ad- 
missions is  of  but  relative  worth  inasmuch  as  reports  of 
this  type  are  not  representative  of  the  status  of  the  whole 
mass  of  population.  The  class  of  patients  frequenting 
large  general  hospitals  is  often  not  a  true  index  of  the  kind 
of  folk  inhabiting  a  given  zone.  Moreover,  it  should 
be  observed  that  not  infrequently  the  statistics  reported 
are  from  hospitals  largely  surgical,  to  which  patients  go 
on  account  of  the  reputed  skill  of  some  operator. 

Table  5  indicates  the  gastric  cancer  admission  ratios 
in  representative  American  and  English  hospitals.     It  is 

Table  5 


Hospital 

Total 
admissions 

Number  of 
gastric 
cancers 

Ratio 

Johns  Hopkins  Hospital 

8,464 
11,812 

9,458 
18,958 
23,500 

4,643 

150 

129 

54 

98 

106 

20 

Ito    56.4 

Mass   General  Hospital 

Ito    91.5 

Montreal  General  Hospital 

Ito  175.0 

St.  Thomas,  London 

Ito  193.6 

St  Bartholomew's,  London 

Ito  221.6 

London  Temperance  Hospital 

Ito  231.2 

Proportion  of  Gastric  Cancer  admissions  to  total  admissions  of  Repre- 
sentative Hospitals. 


GENERAL   DISTRIBUTION   AND    ETIOLOGY 


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24  CANCER   OF   THE    STOMACH 

seen  that  while  in  general  the  above  hospitals  occupy 
similar  positions  in  their  respective  communities,  the 
admission  rates  exhibit  a  wide  range  in  the  frequency  of 
gastric  cancer.  While  in  ratio,  the  London  hospitals 
vary  least,  that  of  American  hospitals  along  the  Atlantic 
seaboard  shows  rather  striking  and  unexplainable  differences. 

Our  921  instances  of  gastric  malignancy  occurred  in 
approximately  82,000  clinical  admissions  for  all  forms  of 
medical  and  surgical  disease.  The  average  age  of  these 
patients  was  about  40  years.  These  figures  return  a  ratio 
of  the  frequency  of  gastric  cancer  of  approximately  1  to 
89  hospital  admissions. 

The  information  returned  from  the  study  of  mortality 
records  is  of  but  relative  value.  Until  recently,  the 
American  mortality  statistics  were  partly  fact  and  partly 
estimate,  owing  to  there  being  but  a  limited  area  of  regis- 
tration. Even  in  registration  areas  the  returns  are  open 
to  question,  inasmuch  as  they  are  based  upon  material 
which  has  been  checked  but  rarely  by  pathologic  re- 
ports. That  mistakes  in  the  diagnosis  of  gastric  cancer 
commonly  occur  even  in  large  city  practice,  is  emphasized 
by  Fenwick.  He  states  that  of  56  cases,  admitted  into 
London  hospitals,  under  his  care,  with  a  diagnosis  of  gastric 
cancer,  in  only  31  (55.3  per  cent.)  was  the  disease  proved 
to  exist.  In  25  instances  (44.7  per  cent.)  the  patients 
were  free  from  the  disease.  These  mistakes  had  occurred 
in  spite  of  the  fact  that  the  average  duration  of  the  illness 
prior  to  hospital  admission  was  nearly  4  months.  An  ex- 
perience similar  to  this  can  be  furnished  by  any  American 
hospital  that  makes  a  practice  of  requiring  a  pathologic 
or  laparotomy  diagnosis,  instead  of  one  based  upon  purely 
clinical    or    chemical    evidence.     Cabot    states    that    in 


GENEKAL   DISTRIBUTION   AND    ETIOLOGY 


25 


his  large  experience  correct  clinical  diagnosis  of  gastric 
cancer  occurred  in  but  72  per  cent,  of  instances. 

Dependable  mortality  reports  indicate  that  gastric 
cancer  furnishes  nearly  38  per  cent,  (or  about  30,000 
cases  annually)  of  all  cancer  deaths.  These  figures  indicate 
that  malignant  disease  of  the  stomach  is  more  common 
than  is  malignancy  of  any  other  organ.  The  rate  is  fully 
10  per  cent,  higher  in  males  than  in  females.  In  the 
latter,  malignancy  of  the  genitalia  and  peritoneum  is 
more  frequent.  These  various  factors  are  well  demon- 
strated in  Table  6. 


Table  6 

(Rates  per  100,000  Population) 

(Ages  40  and  over) 

Males 


Number 


Per  cent. 


Rate  per 
100,000 


Stomach  and  liver 

Rectum,  intestines  and  peritoneum . 

Buccal  cavity 

Skin 

Other  organs 


Total,  ages  of  40  plus . 
Total,  all  ages 


50,157 

11,980 

7,304 

6,252 

23,690 


50.5 

12.1 

7.3 

6.3 

23.8 


99,383 
109,299 


100.0 


96.6 
23.1 
14.1 
12.0 
45.6 


191.4 


Females 


Stomach  and  liver 

Generative  organs 

Breast 

Rectum,  intestines  and  peritoneum . 

Skin 

Buccal  cavity 

Other  organs 


50,388 
35,587 
22,190 
16,751 
3,303 
1,529 
24,598 


Total,  ages  40  plus . 
Total,  all  ages 


154,346 
173,369 


Cancer  Mortality  by  Organs  or  Parts  Affected;  U.  S.  Registration  Area, 
1901-1910.— (Hoffman.) 


26 


CANCER   OF   THE    STOMACH 


The  increase  in  gastric  cancer  is  real  and  alarming.  At 
age  40  and  above,  it  has  increased  more  than  10  per  cent, 
for  both  sexes.     This  is  well  brought  out  by  Table  7. 

Table  7 
(Rates  per  10,000  Population) 


Ages 

Males 

Females 

Actual  excess  in 
female  rate 

Excess 
per  cent. 

30  to  39 

40  to  49 
50  to  59 
60  to  69 
70  to  79 
80  + 

7.8 

34.2 

88.7 

182.9 

262.2 

207.6 

10.2  + 

39.0  + 

99.7  + 

192.2  + 

282.0  + 

201.2  + 

2.4 
4.8 

11.0 
9.3 

19.8 

30.8 

14.0 

12.4 

5.1 

7.6 

40  + 

96.6 

108.2 

11.6 

12.0 

Mortality  from  Cancer  of  the  Stomach  and  Liver;  U.  S.  Registration 
Area,  1901-1910. 

Sex. — Clinical  and  pathologic  data,  compiled  from  hos- 
pital and  dead-house  reports  of  a  half  century  ago,  would 
appear  to  indicate,  with  few  exceptions,  that  gastric  cancer 
is  of  rather  more  frequent  occurrence  in  males  than  in 
females.  Certain  groups  of  statistics  are  often  quoted  in 
support  of  this  statement.  In  1859,  Brinton  declared,  after 
studying  reports  of  600  cases,  that  the  disease  occurred 
twice  as  frequently  in  males  as  in  females.  In  1872,  Fox 
collected  1,303  instances  of  gastric  cancer  from  the  litera- 
ture and  his  own  practice.  There  were  680  males  and  623 
females.  Welch's  analysis  of  2,214  cases  of  gastric  malig- 
nancy (recorded  mainly  in  continental  literature  during  a 
period  when  microscopic  pathology  was  in  its  infancy) 
demonstrates  the  ratio  of  males  to  females  as  5 : 4.  Fen  wick 
claims  a  proportion  of  males  over  females  of  approximately 
6:4.  Friedenwald  has  recently  collected  1,000  cases,  clin- 
ically of  gastric  cancer  (26.6  per  cent,  came  to  laparotomy) 
and  records  that  there  were  588  males  and  412  females. 


GENERAL   DISTRIBUTION   AND    ETIOLOGY 


27 


In  our  series  of  921  cases,  which  were  proven  to  be 
primary  gastric  cancer  operatively  and  pathologically, 
there  were  693  males  and  228  females,  or  3.04  males  to  1 
female. 

This  proportion  is  particularly  interesting  because  it 
comes  from  controlled  material;  it  is  a  distinctively  Ameri- 
can experience;  it  has  been  returned  mainly  from  living 
and  not  dead  subjects;  it  closely  approximates  the  sex 
ratio  which  is  associated  with  simple  chronic  gastric 
ulcer. 


/-J        ,o-,s      2JS-Z9     JO-39     ^-*y      ^0-S9      60-69     TO-JS      80-3}      So-iao 


Chart  IV. — Incidence  of  gastric  cancer  by  age  and  sex.     The  upper  line 
represents  males,  the  lower,  females. — (Author.) 

Age. — According  to  modern  writers,  from  60  to  70  per 
cent,  of  the  deaths  from  gastric  cancer  occur  between  the 
fortieth  and  seventieth  years.  In  the  Hving  the  incidence 
is  commonly  recorded  as  being  greatest  between  the  fiftieth 
and  sixtieth  years.  Necropsy  reports  usually  place  the 
maximum  age  frequency  rather  higher  than  where  such  is 
determined  from  living  patients. 


28 


CANCER   OF   THE    STOMACH 


Table  8  shows  the  age  incidence  by  decades  and  sex  in 
the  material  which  we  have  studied.  Chart  IV  demon- 
strates graphically  the  age  curves  in  relation  to  sex. 


Table  8 


Age 


Male 


Female 


Total 


1  to     9 
10  to  19 

20  to  29 
30  to  39 

40  to  49 
50  to  59 
60  to  69 
70  to  79 
80  + 


0 

0 

0 

0 

1 

1 

4 

5 

9 

54 

34 

88 

159 

73 

232 

284 

66 

350 

160 

40 

200 

31 

9 

40 

1 

0 

1 

693 


228 


921 


Total  Cases  921.     Ratio  Males  to  Females,  3.04  :  1. 

Sex  and  Age  by  Decades. — (Author's  Series.) 


Certain  facts  of  interest  are  brought  out.  The  greatest 
number  of  cases  occurred  in  the  sixth  decade  (350  cases 
between  ages  50-59).  Between  ages  40-69  there  occurred 
84.9  per  cent,  of  all  our  cases.  Ten  instances  (1.20  per 
cent.)  were  tabulated  below  age  30.  One  case  died  of 
gastric  cancer  at  age  19.  In  males  the  greatest  number  of 
cases  feU  between  ages  50-59  (40.9  per  cent,  of  the  total 
for  the  sex),  while  87  per  cent,  of  all  cases  fell  between 
ages  40  and  69.  In  females  the  disease  appeared  to  occur 
at  a  rather  earher  period  of  life  than  in  males.  In  this  sex 
the  greatest  number  of  cases  (73)  were  in  the  fifth  decade, 
while  78  per  cent,  of  all  instances  came  between  ages  40—69. 

Race  and  Nationality. — Friedenwald  states  that  5.2  per 
cent,  of  his  cases  of  gastric  cancer  occurred  in  negroes.  In 
this  race  the  greatest  frequency  of  the  disease  was  in  the 
sixth  decade.     Hoffman  has  made  a  careful  study  of  the 


GENERAL    DISTRIBUTION    AND    ETIOLOGY 


29 


difference  in  mortality  from  cancer  of  the  stomach  and  liver 
in  whites  and  colored  (Table  9). 

Table  9 
(Rates  per  100,000  Population) 


Ages 


Males 


Females 


WHte 


Colored 


WMte 


Colored 


30  to  39 

9.7 

15.2 

8.7 

11.3 

40  to  49 

28.3 

30.5 

31.3 

27.4 

50  to  59 

89.5 

84.4 

87.6 

91.0 

60  to  69 

221.0 

166.4 

151.6 

82.0 

70  + 

268.3 

152.3 

168.5 

160.6 

40  + 


105 . 5 


73.1 


84.5 


64.5 


Mortality  from  Cancer  of  the  Stomach  and  Liver,  by  Races;  District  of 
Columbia,  1901-1910.— (Hoffman.) 

He  observes  that  the  death  rates  for  negroes  exceed 
those  for  whites,  in  males  at  ages  under  50,  and  for  females 
under  40.  Above  such  ages,  the  white  death  rate  is  in 
excess  of  that  of  the  negro.  It  would  seem  also  that  gastric 
cancer  is  becoming  more  prevalent  among  the  American 
negroes.  This  is  shown  by  the  reports  of  the  U.  S.  Dept. 
of  Commerce,  1912-13. 

Our  investigations  record  no  case  of  gastric  cancer  among 
negroes.  This,  doubtless,  happens  because  we  rarely  see 
a  negro  patient. 

While  40.3  per  cent,  of  our  patients  were  American  born, 
yet  nearly  80  per  cent,  were  of  foreign  extraction.  We  have 
attempted  to  classify  these  facts  in  Table  10. 

It  has  been  stated  frequently  that  gastric  cancer  is 
uncommon  in  Jews.  From  a  relatively  small  proportion 
of  Jewish  patients,  our  records  show  17  (1.8  per  cent.) 
cases  in  either  American  or  foreign  born  Jews.  There 
were  11  males  and  6  females.  It  would  appear  that,  Uv- 
ing  under  similar  conditions,  Jews  are  as  prone    to   the 


30 


CANCER   or   THE    STOMACH 

Table  10 


Nationality 

Number  of  cases 

Per  cent,  of  total 

Americans 

372 

170 

143 

108 

73 

18 

12 

11 

4 

3 

2 

2 

1 

1 

1 

40.3 

Irish 

18.0 

Swedish 

15.5 

German 

11.7 

Norwegian 

7.8 

Austrian 

1.9 

Danish 

1.3 

Russian 

1.02 

English 

0.43 

Belgian 

0.32 

French 

0.22 

Italian 

0.22 

Alaskan 

0.10 

Mexican 

0.10 

Portuguese 

0.10 

Total 

921 

100 

Incidence  of  Gastric  Cancer  by  Nationality — (Author.) 

disease  as  are  other  human  famihes.  It  has  been  advanced 
that  the  explanation  for  the  former  supposition  of  the 
lessened  habihty  of  Jews  to  cancer  lay  in  the  fact  that 
Jewish  families  were  usually  large — whence  the  proportion  of 
young  Jews  to  old  was  relatively  great.  At  present  it  is 
not  uncommon  to  find  many  small  Jewish  families  (par- 
ticularly in  America),  probably  as  the  result  of  prosperity, 
heterodoxy,  and  altered  mode  of  life.  This  may  explain 
the  evident  increase  of  gastric  cancer  among  modern 
Jews. 

While  we  have  no  specific  data  to  offer,  our  observations 
would  appear  to  indicate  the  relative  infrequency  of  car- 
cinoma of  the  stomach  among  those  races  far  removed 
from  modern  civilization,  so  called.  It  is  quite  possible, 
however,  that  accurately  compiled  statistics  from  the 
lands  inhabited  by  such  folk  will  eventually  demonstrate 
the    ubiquity   of   the   disease.     Certainly   cases   are    not 


GENERAL   DISTRIBUTION   AND    ETIOLOGY  31 

infrequently  being  reported  from  Japan  (Miyake).  Dr. 
Hie  Ding  Lin  of  Foo  Chow,  China,  personally  assures  me 
that  not  uncommonly  well-to-do  Chinese  die  from  chronic 
gastric  disease,  often  of  a  type  associated  with  cachexia 
and  anemia. 

Occupation. — At  the  present  state  of  our  knowledge, 
it  cannot  be  said  definitely  that  any  one  type  of  work  pre- 
disposes   to    gastric    cancer.     It    has    been    observed   by 
Tatham  that   the   general   cancer   mortality   during   the 
period  1881-1890  was  twice  as  great  among  the  financially 
prosperous,   having  no  particular  occupation,   as  it  was 
among  occupied  males  with  diverse  vocations.     Aschoff 
seems  to  havg  shown  that  Berliners  living  on  incomes  or 
pensions  furnished  the  greater  part  of  the  cancer  mortality 
in  their  section.     Roger  Williams  makes  similar  comments. 
These  general  studies  are  interesting,  but  by  no  means 
conclusive.     It  is  perhaps  possible  that  the  explanation 
for  the  evident  frequency  of  cancer  in  the  retired,  well- 
to-do  part  of  the  population  may  be  found  in  the  observa- 
tion that  this  class  is  mainly  made  up  of  individuals  at 
the  cancer  age.     Relatively  few  persons  succeed  in  amassing 
sufficient  material  wealth  before  the  fifth  decade  to  enable 
them  to  stop  working.     It  will  be  recalled  that  approxi- 
mately 8  out  of  10  cases  of  gastric  cancer  occur  above  age  40. 

We  have  grouped  our  material,  according  to  occupation, 
in  Table  11. 

A  very  striking  feature  of  the  Table  is  the  preponderance 
of  farmers.  The  series  demonstrates  that  32.4  per  cent, 
of  our  instances  of  the  disease  occurred  in  farmers,  active 
or  retired.  The  proportion  of  patients  of  this  type  is 
increased  by  11.3  per  cent,  on  analysis  of  the  group 
labeled  ''housework."  These  patients  were  farm-dwellers, 
living  under  similar  conditions  to  the  males  furnishing  the 


32 


CANCER    OF    THE    STOMACH 


Table  11 


Farmers 

Housework 

Laborers 

Merchants 

Carpenters 

Traveling  salesmen. 

Blacksmiths 

!Miners 

Teamsters 

Ph5'sicians 

Lawyers 

Lumber  dealers 

Clergj^men 

R.  R.  conductors. . . 

Teachers 

Engineers 

Contractors 

Clerks 

Painters 

^Machinists 

Shoemakers 

Salesmen 

Postmen 

Plumbers 

Saloon-keepers 

Ranchers 

Insurance  men 

Druggists 

^Manufacturers 

Grain  dealers 

Stone  cutters 

Liquor  dealers 

Xurses 

Well  drUlers 

Cooks 

Students 

Tailors 

Watchmen 

R.  R.  agents 

Bankers 

Bookkeepers 

Butchers 

Live-stock  men 


299 

187 

43 

39 

19 

16 

14 

10 

10 

10 

9 

9 

9 

S 

8 

7 

7 

6 

6 

6 

6 


Barbers 3 

Car-shop  laborers 3 

Dressmakers 3 

Brewers 3 

Liverj'men 2 

Jewelers 2 

Hotel  keepers 2 

Dairymen 2 

Bridge  buUders 2 

Construction  engineers 2 

Restaurant  keepers 2 

Dentists 2 

Photographers 2 


Electricians 

Peddlers 

Watchmakers 

Printers 

Auctioneer 

Woodsman 

Retired  soldier 

Prison  guard 

Brakeman 

Veterinary  surgeon. 

Policeman 

Optometrist 

Real  estate 

Judge 

Janitor 

Stage  hand 

ElectrotjTDer 

Statistician 

Horse  trainer 

Tinsmith 

SaUor 

Plast-erer 

Stenographer 

Gardener 

Gunsmith 

Brassworker 


2 

2 

2 

2 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

Unclassified 46 


Total 921 


Occurrence  of  Gastric  Cancer  According  to, Occupation. — (Author's  series.) 

''farmer"  class.     Certain  other  so-called    ''out-door"  oc- 
cupations   largely    contributing,    actually    or    relatively, 


GENERAL   DISTRIBUTIOX   AND    ETIOLOGY  33 

to  the  list  are  laborers,  traveling  salesmen,  teamsters, 
ranchers,  stockmen,  Hverymen,  construction  engineers, 
well -drillers,  contractors  and  gardeners.  These  occupa- 
tions make  up  nearly  55  per  cent,  of  our  total.  Even 
when  it  is  considered  that  mam^  of  the  patients  seeking 
relief  at  the  cUnics,  where  our  work  was  done,  are  from 
rural  communities,  yet  the  figures  are  sufficiently  remark- 
able to  warrant  consideration.  In  the  study  of  general 
cancer  etiology,  Wilhams  (loc.  cit.)  has  observed  that 
while  much  of  the  material  which  he  studied  came  from 
Londoners  following  sedentary  occupations,  there  was  a 
strikingly  large  proportion  of  cancer  cases  among  the  group 
engaged  in  out-of-door  work.  Ochsner  has  frequently 
called  attention  to  the  fact  that  many  individuals  affected 
with  gastric  cancer  are  hberal  consumers  of  uncooked  or 
unwashed  vegetables  and  fruits.  This  is  not  an  un- 
common and  preponderant  diet  at  certain  periods  of  the 
year  in  rural  communities.  Urban  populations,  especially 
the  well-to-do,  are  able  also  to  indulge  liberally  in  similar 
deUcacies  and  frequently  all  the  year  round.  In  cities 
there  is  an  increasing  consumption  of  head  lettuce,  radishes, 
cucumbers,  young  onions,  melons,  plums,  peaches,  grape- 
fruit, etc.  It  may  be  that  irritants,  parasitic  or  chemical, 
are  ingested  with  such  unwashed  or  uncooked  foods,  which 
influence  atypic  metaboHsm. 

Our  analysis  fails  to  show  the  immunity  of  printers, 
miners,  quarry-men  or  industrial  workers  to  gastric  cancer. 
It  cannot  be  said  that  there  is  a  pecuhar  susceptibility  to 
the  disease  among  merchants,  brewers,  cooks,  hotel- 
keepers,  domestics,  metal-workers  or  sailors.  In  this 
series  carpenters,  blacksmiths  and  shoemakers  furnish  a 
comparatively  high  proportion  of  instances  of  gastric 
cancer    when   one   recalls    the   limited   number   of   men, 


34  CANCER   OF   THE    STOMACH 

per  population,  actually  engaged  in  such  labor.  Hard 
physical  effort,  the  swallowing  of  nails,  bits  of  wood,  etc., 
combined  with  Hability  to  abdominal  injury,  may  be  a  not 
unimportant  contributing  factor  in  the  production  of  the 
disease. 

Social  Status. — It  has  been  said  that  a  high  cancer 
mortaUty  is  an  indication  of  general  prosperity  (Williams) . 
Material  abundance  in  some  way  appears  to  favor  the 
development  of  malignancy'.  The  highest  cancer  incidence 
is  found  in  those  communities  where  people  are  well 
housed,  well  fed  and  free  from  the  cares  associated  with 
the  struggle  for  bare  existence.  Where  poverty  is  preva- 
lent, as  in  centers  of  dense  population,  prisons,  asylums 
and  almshouses,  cancer  is  relatively  infrequent.  Williams 
has  noted  that  Ireland  has  a  much  lower  cancer  death  rate 
than  has  England.  In  the  former  country  riches  and  the 
concomitant  ease  and  abundance  of  food  are  somewhat 
rare.  ^Moreover,  in  those  parts  of  Ireland  where  the  con- 
ditions of  life  are  hardest  and  the  people  are  uniformly 
under  fed  {e.g.,  Kerry),  the  cancer  mortality  is  lowest. 
In  an  extremely  interesting  study  of  life  insurance  statis- 
tics, Hoffman  proves  that  the  proportionate  mortaUty 
from  cancer  is  measurably  less  among  risks  representative 
of  the  wage-earning  population  than  it  is  among  those 
risks  from  the  prosperous  and  well-to-do  group,  even 
though  the  latter  class  is  subjected  to  more  rigid  medical 
examination  on  entrance.  At  age  40-50,  the  proportionate 
mortality  from  cancer  for  males  was  5.1  per  cent,  in  the 
wage-earning  group  and  6.7  per  cent,  in  the  well-to-do 
division.  For  females  at  the  same  decade,  the  propor- 
tionate mortaUty  was  13.7  per  cent,  for  the  wage-earning 
and  18.5  per  cent,  for  the  prosperous. 

The  patients  comprising  our  series   of   gastric  cancers 


GENERAL   DISTRIBIJTION   AND   ETIOLOGY  35 

were  largely  from  that  great  middle  class  making  up  the 
bulk  of  the  population  of  the  Mississippi  Valley,  the 
northwest  United  States  and  southern  Canada.  There 
were  few  people  extremely  poor  or  uncomfortably  rich. 
The  great  number  was  in  easy  circumstances;  certainly  the 
cases  actually  fighting  for  mere  existence  were  rare. 
A  large  part  of  the  group  was  made  up  of  folk  whose  parents 
were  foreign  born,  or  who  themselves  had  emigrated  from 
other  shores  when  young.  While  the  early  years  of  many 
had  doubtless  been  strenuous,  the  later  life  had  seen  the 
majority  installed  in  comfortable  homes  and  surrounded 
with  many  material  luxuries.  It  has  been  pointed  out 
by  numerous  writers  that  just  this  type  of  population 
furnishes  the  mass  of  the  never-ending  cancer  army.  The 
environmental  change,  the  unaccustomed  abundance  of 
meat  and  drink,  combined  with  sedentary  life  at  the  cancer 
age  and  the  urbanization  of  a  class  of  people  previously 
largely  rural,  appear  to  stimulate  the  metabolism  of  cells 
that  are  perhaps  already  of  perverted  tendency. 

Conjugal  State. — Of  our  entire  series  806  patients 
(87.5  per  cent.)  were  married  or  were  widows  or  widowers. 
Fifty-two  were  single.  The  status  of  63  was  not  noted. 
In  our  series  there  were  7  instances  where  gastric  cancer 
had  developed  in  man  or  wife  within  5  months  of  its  in- 
ception or  the  fatal  issue  in  the  other. 

Diet  and  Nutrition. — Accumulated  evidence  fails  to 
demonstrate  that  especial  frequency  of  gastric  cancer  can 
be  attributed  to  over-indulgence  in  any  particular  kind  of 
food.  Except  in  rare  instances,  chronic  over-eating  appears 
to  be  more  detrimental  to  the  stomach  than  does  the  kind  of 
viands  ingested.  Statistical  evidence  in  proof  of  this  state- 
ment is  not  lacking.  Reviewing  the  investigations  of  the 
Actuarial   Society   of  America,   Hoffman  states   that  an 


36  CANCER   OF   THE    STOMACH 

analysis  of  the  relation  of  the  physique  of  life  insurance 
applicants  at  entry  to  causes  of  death  was  made.  Those 
applicants  who  were  over-weight  at  entry  returned  cancer 
death  rates  (age  15-19)  of  0.9  per  10,000,  while  the  under- 
weights in  the  same  group  had  a  cancer  mortality  of 
0.8  per  10,000.  At  ages  30-44,  the  cancer  mortality  of 
over-weights  was  3.7  per  10,000  and  of  under-weights  2.4. 
At  age  45  and  over,  the  cancer  mortality  of  over-weights 
was  15.6  and  of  under-weights  12.0  per  10,000. 

That  excessive  feeding  puts  unnecessary  work  upon  the 
digestive  glands  is  quite  within  reason.  That  this  highly 
specialized  type  of  gland  may  be  stimulated  to  chronic 
over-activity  by  excessive  amounts  of  food  is  well  within 
the  bounds  of  known  physiology.  What  effect  upon 
intraglandular  metabolism  this  demand  for  special  products 
may  have  we  can  but  conjecture.  It  might  be  suggested 
that  should  these  excessive  demands  ultimately  leave  an 
exhausted  cell — that  is,  exhausted  in  so  far  as  its  specific 
function  is  concerned — such  cell  might  not  only  be  more 
susceptible  to  trauma  (mechanical,  chemical  or  parasitic), 
but  reasonably  might  be  expected  to  proliferate  in  a' 
vegetative,  undifferentiated  manner  due  to  the  stimulus 
of  its  individual  over-nourishment. 

Careless  mastication  or  the  indulgence  in  hot  or  cold 
liquids  appears  to  have  little  significance  apart  from  the 
possibilities  of  intragastric  trauma. 

Upon  extremely  slender  evidence,  it  has  been  held 
that  excess  of  proteid  food  was  responsible  for  the  preva- 
lence of  gastric  cancer.  While  such  excess  may  be  a 
contributory  factor  to  a  cause  of  the  disease,  yet  it  will 
be  recalled  that  gastric  cancer  is  rarely  found  in  the  North 
American  Indian  or  the  Esquimaux.  The  great  labor- 
ing classes  in  the  United  States  consume  astonishingly 


GENERAL   DISTRIBUTION    AND    ETIOLOGY  37 

large  amounts  of  proteid  food,  and  yet  in  these  groups 
cancer  has  a  low  ratio  of  incidence.  Our  investigations 
demonstrate  that  less  than  7  per  cent,  of  the  patients 
were  excessive  proteid  eaters,  while  58.8  per  cent,  subsisted 
upon  a  mixed  diet.  Dietetic  information  was  not  ob- 
tained regarding  29  per  cent,  of  cases. 

Certain  sects  have  in  some  unexplained  way  convinced 
themselves  that  abstinence  from  proteids  (meats,  eggs,  etc.) 
prevents  alimentary  cancer.  Rather  more  than  5  per  cent, 
of  our  cases  either  had  refrained  from  meat  for  years  or 
had  been  strict  and  life-long  vegetarians.  As  we  have 
shown  above,  more  than  half  of  our  cancer  cases  came  from 
people  living  in  small  towns  or  rural  communities,  where 
an  abundance  of  vegetables  and  fruit  is  eaten.  Among 
many  such  people  fresh  meat  is  eaten  rarely  more  than 
three  times  weekly.  Whether  or  no  the  ingestion  of  an  excess 
of  raw  or  unwashed  vegetables  or  fruits  acts  unfavorably 
upon  the  gastric  lining  has  not  yet  been  proven.  How- 
ever attractive  may  be  the  theory,  there  is  certainly  no 
experimental  evidence  that  a  parasite  causing  gastric 
cancer  is  introduced  into  the  body  in  this  way.  Fenwick, 
quoting  Hendly,  states  that  of  102  patients  who  were 
operated  upon  for  general  carcinoma  at  Jeypore,  India, 
between  1880  and  1888,  59.8  per  cent,  were  life-long 
vegetarians. 

Alcohol. — While  there  is  much  carelessly  expressed 
opinion  upon  the  matter,  there  is  no  proof  that  the  partak- 
ing of  alcoholic  liquors  predisposes  to  gastric  cancer.  In 
this  relation,  Williams  calls  attention  to  the  following 
significant  facts :  Of  several  hundred  female  cancer  pa- 
tients, the  majority  had  led  sober  lives;  of  116  male  cancer 
patients,  aged  from  40-65,  50.7  per  cent,  had  been  total 
abstainers   or  habitually  temperate,   25.7  per  cent,   had 


38  CANCER   OF   THE    STOMACH 

been  irregular  drinkers,  while  22.3  per  cent,  had  been 
constant  indulgers;  the  increase  in  alcoholism  among 
women  has  been  relatively  greater  than  among  men,  yet 
cancer  has  proportionately  increased  among  males;  while 
it  has  been  stated  that  those  whose  occupations  permit 
of  special  facility  in  obtaining  alcoholic  drinks  (hotel 
keepers,  brewers,  traveling  salesmen,  etc.)  have  a  rela- 
tively high  cancer  mortality,  it  has  also  been  noted  that 
individuals  engaged  in  certain  vocations  where  drinking  is 
very  common  (printers,  iron  and  steel  workers,  com- 
positors, paper  makers,  miners,  etc.)  appear  to  be  less 
prone  to  cancer  than  do  their  fellows  in  the  same  com- 
munity; and  lastly,  although  cancer  mortality  is  high  in 
certain  alcohol-consuming  countries  (Bavaria,  Saxony), 
other  sections  equally  intemperate  (Spain,  Italy,  West 
Ireland)  return  a  relatively  low  cancer  death  rate.  Fen- 
wick  claims  that  nearly  40  per  cent,  of  his  patients  at  the 
London  Temperance  Hospital  were  total  abstainers.  Re- 
viewing 150  cases  of  the  disease,  Osier  and  McCrae  state 
that  51.3  per  cent,  had  used  alcoholic  drinks,  but  only  5.33 
per  cent,  gave  history  of  excessive  indulgence. 

We  have  definite  figures  with  reference  to  258  males 
of  our  921  gastric  cancer  cases.  In  females  the  question 
was  frequently  not  put  when  taking  the  history.  Of  this 
group  53  (20.6  per  cent.)  were  total  abstainers.  Of  the 
205  remaining  cases  11  (5.3  per  cent.)  were  pronounced 
topers.  The  balance  claimed  either  an  occasional  debauch 
or  took  small  quantities  of  beer,  light  wines,  "hard" 
cider  or  whiskey,  as  the  desire  visited  them. 

Habits. — Tobacco. — Of  423  males  from  whom  we  were 
able  to  obtain  information,  272  or  64.3  per  cent,  used  to- 
bacco in  some  form.  Of  these,  41  or  15.1  per  cent,  were 
excessive  smokers. 


GENERAL   DISTRIBUTION   AND   ETIOLOGY  39 

Venereal  Disease. — Definite  information  was  possible 
in  504  males.  Of  this  number  43  (8.5  per  cent.)  admitted 
gonorrhea  and  6  (1.2  per  cent.)  had  had  hard  chancres. 
It  is  quite  possible  that  the  proportion  of  those  actually 
having  had  venereal  disease  is  higher  than  our  figures  indi- 
cate. While  the  incidence  of  gonorrhea  and  syphilis 
among  these  gastric  patients  appears  to  have  little,  if  any, 
direct  etiologic  bearing  upon  the  disease,  yet  the  ad- 
mission of  such  infection  is  a  certain  useful  index  of  the 
patient's  general  habits. 

Traumatism. — Such  may  be  mechanical,  chemical,  bio- 
chemical or  parasitic.  Injury,  mechanically,  to  the  gastric 
lining  may  result  from  ingestion  of  hard  chunks  of  food 
or  foreign  bodies.  Only  rarely  do  such  injure  normal 
gastric  mucosa.  When  such  a  lesion  as  peptic  ulcer,  atro- 
phic gastritis  or  neoplasm  already  exists,  the  consequence 
of  frequent  temporary  irritation  (as  improper  food)  or  a 
constant  irritant  (foreign  body)  cannot  be  overlooked. 
Carcinomatous  change  may  be  incited  in  benign  gastric 
ulcer,  as  shown  by  Fiitterer,  or  acceleration  in  the  rate  of 
growth  of  a  neoplasm  already  present  might  be  expected. 
It  is  quite  possible,  although  as  yet  unproved,  that  chemical 
irritants  (alcohol,  tobacco  juice,  etc.)  or  biochemical 
bodies  (as  the  end  digestion  products  of  certain  foods  or 
substances  formed  as  result  of  their  deterioration)  may 
act  similarly.  That  parasites  ingested  in  food  are  capable 
of  actually  causing  certain  atypic  growths  appears  to 
have  been  shown  recently  by  Fibiger.  As  a  consequence' 
of  his  feeding  rats  upon  roaches  infested  with  a  certain 
nematode,  growths  of  a  cancerous  type  developed  in  a 
large  number  of  the  stomachs  of  such  rats. 

That  external  traumata  of  mechanical  type  sometimes 
influence  the  development  of  gastric  malignancy  appears 


40  CANCER    OF    THE    STOMACH 

proved.  One  cannot  always  state  that  such  injury  deJfi- 
nitely  caused  cancer  to  develop,  but  there  would  seem  to 
be  abundant  evidence  that  latent  processes  may  be  aroused 
to  activity  following  certain  injuries. 

We  had  21  patients  (2.6  per  cent.)  where  traumata  had 
occurred  shortly  before  the  onset  of  gastric  malignancy. 
In  14  of  these  (1.5  per  cent.),  injuries  occurred  in  the  early 
history  of  the  affection  and  were  shortly  followed  by  the 
appearance  of  symptoms.  The  traumata  were  usually 
blows,  falls  or  kicks  in  the  abdomen,  or  crushing  accidents 
from  such  events  as  being  run  over  by  a  vehicle.  The 
following  case  is  illustrative: 

F.  V. — Male,  age  52,  teamster.  Comes  on  account  of 
epigastric  distress,  weakness,  weight  loss  and  recent  hem- 
atemesis  and  melena. 

Family  history  negative.  Denies  venereal.  Up  to  2 
3^ears  ago  was  in  perfect  health.  At  that  time  was  thrown 
from  a  wagon.  FeU  hard  upon  his  back,  and  was  confined 
to  bed  for  a  week.  On  getting  about  again  noted  burning 
sensation  in  epigastrium,  usually  several  hours  post  cibo  and 
at  night.  This  distress  occurred  on  and  off  and  was  never 
severe.  Relief  was  gained  by  rest,  diet,  and  medicine 
given  him  by  physician  (alkali?).  Appetite  and  bowels  re- 
mained negative.  There  was  some  bloating  and  flatulence. 
Nothing  different  from  the  above  was  observed  until 
about  3  months  ago.  At  that  time  he  received  a  severe 
blow  in  the  ''pit "  of  the  stomach.  His  ''wind  was  knocked 
out"  and  he  suffered  rather  acute  distress  for  a  half  hour. 
Several  hours  afterward  he  vomited  about  a  pint  of  blood 
mixed  with  food.  He  felt  "sick  all  over"  and  perspired 
rather  profusely.  For  2  or  3  days  afterward  he  passed 
black  stools.  He  has  "never  been  himself  since."  He  has 
continuous  burning  in  epigastrium  and  no  appetite. 

Condition  on  examination  revealed  weight  loss  of  40 
pounds  (in  about  2  months);  hemoglobin,  87  per  cent.; 
considerable  emaciation,  and  a  movable  nodule  in  the 
upper,  mid-epigastrium. 

Test-meal  revealed  free  Hcl,  0;  total  acidity,  64.     There 


GENERAL   DISTRIBUTION    AND    ETIOLOGY  41 

were  lactic  acid  and  altered  blood  present.  Glycyl- 
tryptophan  test  was  positive.  Pyloric  obstruction  was 
proved  by  persistent  12-hour  food  retention. 

Microscopically,  Oppler-Boas  bacilli  were  seen  in  abun- 
dance. 

Laparotomy  disclosed  an  irremovable  carcinoma  involving 
the  entire  pyloric  region  of  the  stomach.  The  perigastric 
lymph  glands  were  involved.  Anterior  gastro-enterostomy 
was  performed.     The  patient  died  11  days  afterward. 

Hygiene. — We  have  called  attention  to  the  fact  that 
approximately  half  of  our  patients  came  from  rural  com- 
munities or  small  towns.  The  majority  of  these  people 
were  farmers  or  had  lived  upon  farms.  Many  subjects  were 
foreign  born  or  of  alien  parentage.  While  the  plane  of 
life  of  the  American  farmer  is  relatively  high,  yet  it  must 
be  admitted  that  both  general  and  personal  hygiene  are 
susceptible  of  improvement.  This  is  especially  so  among 
immigrant  farmers.  One  not  infrequently  sees  housing 
conditions  for  horses  and  stock  practically  as  perfect  as 
those  for  the  landsman  himself.  The  residence  is  generally 
built  after  other  things  have  been  adequately  taken 
care  of.  Consequently,  over-crowding,  with  lack  of  fresh 
air  and  sunlight,  are  quite  as  common  in  country  homes  as 
in  those  located  in  towns.  Bath-rooms  are  comparatively 
rare  in  the  homes  of  the  average  foreign-born  farmer. 
Privies  of  the  disgusting  and  dangerous  well-type  are  gen- 
erally located  near  the  farm  dwelling,  and  lavishly  hos- 
pitable to  hosts  of  infection-spreading  insects.  Poorly 
covered  drinking-wells  are  the  rule.  Cattle-yards  are 
generally  conveniently  adjacent  to  kitchen-gardens  and 
milk-houses,  and  hence  are  a  constant  source  of  pollution. 

While  it  cannot  be  said  that  this  existing  state  of  affairs 
is  directly  responsible  for  the  prevalence  of  gastric  disorders, 
particularly  ulcer   and   cancer,   among   farmers,   it   must 


42  CANCER   OF   THE    STOMACH 

be  recognized  that  the  stage  is  perfectly  set  for  the  enactioD 
of  any  disease  drama  to  which  a  rural  population  may  be 
susceptible.  The  home  envu'onment  would  seem  not 
infrequently  to  counteract  whatever  tendency  toward 
longevity  the  farming  element  might  acquire  by  virtue  of 
its  physically  active,  open-air  life.  Over-eating  and  the 
sedentary  habit  is  common  during  at  least  a  third  of  the 
year  among  farmers.  During  the  relatively  inactive 
winter  months,  their  diet  is  not  reduced  from  that  upon 
which  they  worked  during  the  periods  of  tilUng,  seed  time 
and  harvest.  Not  rarelj^  added  richness  of  food  is 
supplied  by  a  home-cured  porker,  a  beef  or  by  the  mul- 
titudinous examples  of  peasant  culinary  art  whose  crea- 
tion a  full  larder  tempts.  As  a  result  of  this  prolonged 
gastronomic  debauch,  late  winter,  spring  and  early  summer 
are  seasons  during  which  digestive  disturbances  among 
inhabitants  of  rural  communities  are  so  prevalent  as  to 
be  almost  fashionable,  i.e.,  they  are  an  index  of  prosperity. 
Teeth. — Relatively  few  foreign-born  farmers  and  many 
of  native  parentage  pay  any  attention  whatever  to  oral 
cleanliness.  In  our  experience  with  this  class  of  citizen, 
gastric  cancer  and  filthy  mouths  go  hand  in  hand.  Dirty, 
decaying,  infected  teeth,  loosely  imbedded  in  soggy, 
swollen,  pus-laden  gums,  not  only  prevent  proper  mastica- 
tion of  food,  but  also  act  as  reservoirs  from  which  a  con- 
stant supply  of  poison  passes  into  the  lymph-  and,  perhaps, 
blood-streams.  From  such  mouths  can  be  isolated  virulent 
cocci,  baciUi,  spirochsetse,  leptothrix,  flagellate  protozoa 
(cercomonads,  trichomonads),  and  amoebse.  Pyorrhea 
alveolaris  is  a  \dsible,  local  evidence  of  the  damage  which 
this  infection  may  cause.  We  have  no  means  of  knowing 
at  present  what  effect  upon  gastric  mucosa  such  organisms 
may  have  as  result  of  their  passing  into  the  circulation  or 


GENERAL   DISTRIBUTION   AND    ETIOLOGY  43 

from  their  lodgment  and  growth  upon  a  damaged  gastric 
Hning.  What  upset  of  gastric  physiology  may  result  from 
the  constant  ingestion  of  millions  of  microorganisms  and 
the  products  of  their  growths  we  can  but  conjecture.  Cer- 
tainly it  is  difficult  to  see  how  such  intake  can  be  in  any 
way  beneficial. 

From  microscopic  study  of  the  gastric  extracts  of  2,406 
different  individuals  affected  with  "stomach  trouble,"  I 
have  shown  that  irrespective  of  the  degree  of  acidity  of  such 
gastric  extracts,  bacteria  could  be  isolated  in  87  per  cent. 
Degree  of  gastric  acidity  is  by  no  means  an  index  of  the 
stomach's  cleanliness  bacteriologically.  In  my  studies, 
cocci  and  diplococci  were  present  in  83  per  cent.,  short 
and  long  rods  (often  of  the  colon  group)  in  58  per  cent., 
streptococci  in  17  per  cent.,  and  Leptothrix  buccalis  in  24 
per  cent.  In  cultural  studies  of  the  saliva  from  more  than 
300  dyspeptic  patients,  I  showed  that  streptococci  and 
staphylococci  could  be  obtained  in  80  per  cent.,  bacilli 
in  66  per  cent.,  and  leptothrix  in  14  per  cent.  It  would 
seem  that  many  mouth  organisms  thrive  in  gastric  juice, 
and  only  rarely  is  the  degree  of  hydrochloric  acid  sufficiently 
high  to  act  as  a  germicide  or  to  retard  bacterial  proliferation. 
I  also  showed  that  saliva  from  the  dirty  mouths  of 
dyspeptics  not  infrequently  contains  the  amino-acid 
tryptophan,  and  that  more  than  90  per  cent,  of  such  salivse 
hold  a  ferment  (?)  capable  of  cleaving  the  dipeptid 
glycyltryptophan. 

Heredity. — In  our  series,  a  family  or  blood-relationship 
history  of  cancer,  generally,  was  obtained  from  78  indi- 
viduals (8.5  per  cent.).  Of  this  number,  an  hereditary 
history  of  gastric  cancer  was  noted  in  46,  58.9  per  cent, 
of  the  group  and  4.9  per  cent,  of  the  total  number  of  cases 
(921). 


44  CANCER   OF   THE    STOMACH 

Our  material  fails  to  demonstrate  a  predisposition  to 
gastric  cancer  among  children  of  the  same  sex  as  the  affected 
parent,  a  view  which  has  been  advanced  by  some  clinicians 
{e.g.,  Fenwick).  In  11  instances  where  sons  were  cancerous 
the  mother  had  had  a  like  ailment;  of  such  mothers  there 
were  2  cancerous  daughters.  There  were  11  instances 
where  fathers  had  succumbed  to  gastric  malignancy. 
In  this  group  there  were  9  males  and  2  females.  There 
were  recorded  15  cases  where  brothers  and  sisters  were 
affected  with  the  disease.  One  male  was  observed  both  of 
whose  parents  had  died  from  gastric  malignancy.  Another 
patient,  aged  39,  reported  the  recent  death  from  cancer 
of  the  stomach  of  a  brother  and  a  sister.  There  were  2 
females  whose  uncles  had  died  with  the  disease  and  2 
males  whose  grandfathers  had  been  likewise  affected. 

While  heredity  appears  to  play  a  part  in  the  predis- 
position to  cancer  in  certain  families,  yet  we  feel  from 
the  analysis  of  our  material  that  the  exact  significance  of 
such  influence  is  at  present  unknown.  It  may  be  that  the 
transmission  by  parents  to  offspring  of  a  mode  and  con- 
duct of  life  is  a  factor  not  without  importance,  Galton's 
famous  twins  to  the  contrary  notwithstanding. 

Certain  classic  cancer  families  are  frequently  men- 
tioned. Napoleon  I,  his  father,  his  brother  and  two 
sisters  (Pauline  and  Caroline)  are  said  to  have  died  of 
gastric  cancer.  Monichon  states  that  of  23  families  with 
whose  history  he  was  conversant,  there  were  69  cancerous 
members;  of  these,  57  were  affected  with  gastric  cancer. 
Fenwick  mentions  a  family  where  a  father,  his  sister  and 
three  brothers  all  succumbed  to  the  disease.  Williams 
gives  the  following  interesting  analysis  of  a  cancer  family 
in  which  certain  other  cancer  lesions  were  associated  with 
142  consecutive  uterine  cancers. 


GENERAL    DISTRIBUTION   AND    ETIOLOGY  45 

Table  12 


Member  of  family 


Part  affected 


Father's  brother  (m  1  family) 

Father's  brother  and  3  cousins  (in  1  famUy) . . 

Father's  sister  (in  3  families)  

Maternal  grandmother  (in  1  family) 

Mother  (in  9  families) 

Mother's  sister  (in  6  families) 

Mother's    brother    and    child    of    mother's 
sister  (in  4  families)  

Patient's  sister  (in  8  families) 

Patient's  brother  (in  1  family) 

Patient's  daughter  (in  1  family) 


Face 

Stomach  (brother) 

Breast  (female  cousin) 

Neck  (male  cousin) 

Foot  (male  cousin) 

Uterus 

Intestine 

Arm 

Uterus 

Uterus  (2) 

Breast  (2) 

Stomach  (2) 

Intestine 

Abdomen 

Face 

Uterus  (2) 

Breast  (2) 

Not  stated  (2) 

Stomach  (brother) 

Face  (brother) 

Not  stated  (brother) 

Stomach  (sister's  child) 

Uterus  (6) 

Breast  (2) 

Stomach 

Uterus 


Summary. — Seats  of  hereditary  disease,  38.  Groups: 
uterus  13,  breast  7,  stomach  6,  locaUty  not  stated  3, 
intestine  2,  abdomen,  arm  and  foot,  each  1. 

The  transmission  of  the  same  type  of  mahgnant  tumor 
to  homologous  organs  has  been  emphasized  by  Virchow 
in  the  case  of  anal  melanosis  in  horses.  The  susceptibiHty 
to  tumor  implantation  in  strains  of  laboratory  animals  is 
common  knowledge  (Slye).  Similarly  in  humans,  the 
hereditary  features  have  been  brought  out  with  reference 
to  cancer  of  the  penis,  melanotic  sarcoma,  glioma  and 
sarcoma  of  the  kidney. 


46  CANCER   OF   THE    STOMACH 


ASSOCIATION  WITH  OTHER  GASTRIC  DISEASE 

1.  Gastric  Ulcer. — (a)  Its  relation  to  gastric  cancer. 
Chapter  VIII  considers  this  question  in  detail.  It  is  proper 
to  remark  here  that  there  has  been  much  ancient  and 
recent  controversy  regarding  the  question  of  the  fre- 
quency of  the  association  of  benign  gastric  ulcer,  of  the 
type  pathologically  chronic,  and  carcinoma  of  the  stomach. 
It  is  somewhat  striking  that  those  internists,  pathologists 
and  surgeons  who  have  only  meager  evidence  to  present 
most  staunchly  proclaim  that  such  transition  but  rarely 
occurs.  Pathologists  and  clinicians  acquainted  with  and 
practising  modern  methods  admit  that  the  question  is 
still  unsettled  in  many  of  its  phases.  They  maintain, 
however,  that  until  we  are  thoroughly  acquainted  with  the 
facts  bearing  upon  the  cause  and  life  history  of  gastric 
ulcer  and  of  gastric  cancer  there  is  but  little  hope  of  scientif- 
ically proving  how  many  benign  gastric  ulcers  become 
malignant  and  how  many  continue  to  pursue  a  benign 
course.  At  present  neither  pathologist  nor  clinician  can 
prognose  the  future  course,  histologically  or  cUnically,  of 
any  gastric  ulcer,  acute  or  chronic.  In  so  far  as  many 
ulcera  carcinomatosa  and  early  gastric  cancers  present 
symptoms  which  it  is  common  to  associate  with  benign 
peptic  ulcer,  it  behooves  us  to  cease  a  valueless  con- 
troversy over  the  frequency  with  which  gastric  ulcers 
become  cancers,  and  to  devote  our  energies  to  the  dis- 
covery of  diagnostic  procedures  which  will  enable  us  to 
recognize  early  malignancy,  whether  such  arise  in  ulcer  or 
primarily,  from  a  previously  healthy  gastric  lining.  By 
so  doing  we  can  serve  humanity  and  increase  the  sum  of 
histologic  and  clinical  knowledge. 

(6)  Benign  peptic  ulcers  are  found  sometimes  in  asso- 


GENERAL   DISTRIBUTION   AND    ETIOLOGY  47 

elation  with  gastric  carcinomata.  Our  observations  re- 
vealed 12  instances  where  such  combination  occurred. 
In  these  cases  it  is  often  impossible  to  separate  the  pictures, 
clinically,  until  the  neoplasm  has  brought  about  definite 
constitutional  changes  due  to  local  digestive  disturbances 
and  malignant  intoxication.  Our  series  also  demonstrated 
the  concomitance  of  benign  duodenal  ulcer  and  gastric 
cancer  8  times. 

2.  Gastric  Syphilis. — Unless  negative  Wassermann  reac- 
tion is  returned,  it  is  never  possible  to  exclude  gastric 
syphilis  in  patients  with  history  of  lues  and  chronic  dys- 
pepsia associated  with  weight  loss,  anemia,  achylia 
gastrica  or  epigastric  tumor.  There  were  9  such  cases 
among  our  patients.  It  is  quite  hkely  that  more  extensive 
serologic  investigations  upon  those  so-called  ''atypical" 
gastric  neoplasms  will  demonstrate  an  increasing  number 
of  tumors  which  have  a  luetic  etiology. 

3.  Tuberculosis. — The  stomach  is  rarely  involved  in 
tuberculous  processes.  Only  1  of  our  cases  had  associated 
with  gastric  cancer  an  ulcer  which  appeared  grossly  and 
histologically  tuberculous. 

4.  Achylia  Gastrica. — That  the  absence  of  gastric  se- 
cretions alone  does  not  predispose  to  carcinoma  of  the 
stomach  appears  to  be  borne  out  by  the  clinical  and 
laboratory  evidence  that  patients  with  "primary"  achylia 
can  exist  quite  comfortably  for  many  years  without  cancer 
resulting.  Also,  in  the  various  secondary  and  essential 
anemias  there  is  almost  uniformly  an  absence  of  gastric 
secretion,  without  the  succeeding  development  of  a 
neoplasm. 

5.  Actinomycosis. — Microscopic  examination  of  the  tu- 
mor mass  in  1  of  our  cases  revealed  medullary  cancer  in 
association   with   abundant    growth    of   ray   fungi.     The 


48  CANCER   OF   THE    STOMACH 

patient  was  a  male,  farmer,  without  oral,  nasal,  pulmonary 
or  body  surface  focus  of  actinomycosis. 

ASSOCIATION  OF  GASTRIC  CANCER  WITH  EXTRAGASTRIC 

DISEASE 

1.  Malignancy  Primary  in  Other  Organs.^ — In  5  female 
patients  gastric  cancer  occurred  as  a  metastatic  process 
from  cancer  of  the  breast.  In  3  females  primary  cancer 
of  the  genitalia  was  followed  by  stomach  involvement. 
Three  males  had  gastric  neoplasms  in  association  with 
hepatic  cancer.  In  2  females  cancer  of  the  gall-bladder  re- 
sulted in  succeeding  gastric  involvement.  In  3  instances 
(2  males  and  1  female)  malignancy  of  the  colon  was  re- 
sponsible for  the  stomach  lesion.  Adenomata  of  the  thyroid 
were  concomitant  in  3  instances. 

2.  Cholelithiasis  and  Cholecystitis. — -Gall-stones  had 
previously  been  removed  or  were  noted  at  laparotomy  in 
18  of  our  patients.  Cholecystitis  in  recognizable  degree 
was  observed  in  28  of  214  patients  where  note  was  made. 
In  46  cases  the  appendix  had  previously  been  removed  or 
was   removed   at   the   operation   for  cancer. 

3.  Infectious  Diseases. — (a)  Tuberculosis. — Many  writers 
have  observed  the  frequency  of  healed  tubercles  in  the 
lungs  at  autopsies  of  those  who  have  died  from  gastric 
cancer.  Fenwick  noted  such  in  15.8  per  cent.  It  has 
also  been  advanced  that  various  forms  of  tuberculosis  are 
more  than  ordinarily  common  in  families  where  cancer 
later  develops.  Williams  states  that  50  per  cent,  of  his 
cases  of  uterine  and  mammary  cancer  had  tuberculous 
family  history;  Osier  reports  such  in  more  than  31  per 
cent,  and  Fenwick  26  per  cent,  of  gastric  cancers.  In  our 
series  there  was  a  family  or  blood-relationship  history  of 
tuberculosis  in  26  instances  (4.3  per  cent.)  where  definite 


GENERAL    DISTRrBUTIOX    AND    ETIOLOGY  49 

facts  were  obtainable.  It  is  suggested  that  inasmuch 
as  the  great  mass  of  cancer  deaths  occurs  after  the  fifth 
decade,  age  alone  may  account  for  the  prevalence  of 
healed  tubercles  in  the  lungs  of  15  per  cent,  or  more  of 
these  subjects.  Their  presence  at  necropsies  of  adults 
is  by  no  means  uncommon  in  individuals  dying  from 
diseases  other  than  gastric  cancer. 

(b)  Rheumatism. — In  38  cases  (4.1  per  cent.)  chronic 
rheumatoid  affections  were  recorded.  There  were  cardiac 
leakages  in  14  instances. 

(c)  Malaria. — -It  has  been  claimed  that  carcinoma  is 
not  common  in  regions  where  malaria  is  endemic.  Table 
VI  shows  that  our  lowest  cancer  death  rates  occur  in  North 
Carolina  and  Kentucky,  sections  of  the  United  States 
where  malaria  is  frequently  endemic  and  active.  Study  of 
our  records  of  gastric  cancer  patients  demonstrates  that 
of  732  cases  where  definite  information  was  possible 
17  instances  (2.3  per  cent.)  were  recorded.  This  is  a  rela- 
tively high  figure  inasmuch  as  comparatively  few  of  our 
cases  come  from  the  South. 

(d)  Typhoid  Fever. — A  remarkably  large  proportion  of 
our  patients  gave  a  history  of  having  had  t}-phoid  fever. 
Of  689  instances  where  data  were  available  92  patients 
(14.8  per  cent.)  had  been  affected  with  the  disease. 

(e)  Other  Infectious  Diseases. — Yellow  fever  was  noted 
in  1;  gonorrhea  in  43;  asiatic  cholera  in  1;  erysipelas  in  2; 
pleurisy  in  3;  smallpox  in  3;  mumps  in  12;  scarlet  fever 
in  18;  tonsillitis  or  quinsy  in  20;  diphtheria  in  22;  pneu- 
monia in  29;  measles  in  34;  la  grippe  in  54. 

4.  Parasitic  Infections. — Seven  patients  had  passed 
tape-worms  at  some  period  of  their  lives.  In  one  case  a 
tape-worm  passed  6  weeks  before  the  patient  came  under 
observation,  appeared  to  precipitate  mahgnant  symptoms. 


50  CANCER    OF    THE    STOMACH 

Protozoa  were  isolated  from  the  stools  in  11  cases. 
They  were  found  as  follows:  trichomonas  hominis  4,  cer- 
comonas  hominis  2,  endamcebse  4,  and  balantidium  coh  1. 

5.  Constitutional  Diseases. — Asthma  was  observed  in 
31  instances;  Bright's  disease  18  times;  cirrhosis  of  the  liver 
4  times;  gout,  eczema  and  diabetes  each  3  times. 

REFERENCES 

Buday:  Conference  Internationale  du  Cancer,  Paris,  1910,  p.  89. 

Hoffman,  F.  L.  :  Transactions  of  the  American  Gynecological  Society, 
1913;  and  Surg.,  Gyn.  and  Obst.,  1914,  June,  p.  726. 

Fenwick,  S.:  "Cancer  and  Other  Tumors  of  the  Stomach,"  Phila- 
delphia, 1903. 

C-\BOT,  R.:  Jour.  Amer.  Med.  Assn.,  1912,  Dec.  28,  p.  2295. 

Brinton,  W.  W.:  "Diseases  of  the  Stomach,"  1859;  and  Brit,  and  For. 
Chir.  Rev.,  1857,  January. 

Fox,  W.:  "The  Diseases  of  the  Stomach,"  London,  1872. 

Welch,  W.:  "Cancer  of  the  Stomach,"  Am.  Syst.  Med.,  II. 

Friedenwald,  J.:  Am.  Jour.  Med.  Sc,  1914,  Nov.,  p.  660. 

Miyake:  Sei-I-Kwai  :\Ied.  Journ.,  Tokio,  1914,  May  10,  No.  5. 

Tatham:  Supplement  to  Registrar-General's  Fifty-fifth  Annual  Report, 
1897  (London). 

Aschoff:  Cited  by  Williams. 

Williams,  R.:  "The  Natural  History  of  Cancer,"  New  York,  1908. 

OsLER  AND  jMcCrae:  "  Cancer  of  the  Stomach,"  Philadelphia,  1900. 

FiJTTERER,  G.:  Quoted  by  Mayo  Robson  and  Moynihan,  "Diseases  of 
the  Stomach,"  1904. 

Fibiger:  Berl.  Klin.  Wochnschr.,  1913,  Feb.  17,  p.  289. 

Galton:  Journal  of  the  Anthropological  Institute,  1876,  vol.  v,  p.  391. 

Monichon:  These  de  Paris,  1896,  No.  415. 

ViRCHOw:  Onkologie,  II,  p.  352. 

Slye:  Interstate  Medical  Journal,  1915,  July. 

Smithies:  Arch.  Int.  Med.,  1912,  Dec,  p.  1. 


CHAPTER  II 

MORBID  ANATOMY:  GROSS,  MICROSCOPIC  AND 
EXPERIMENTAL 

CLASSIFICATION  OF  GASTRIC  NEOPLASMS 

By  clinicians,  gastric  tumors  are  usually  grouped  as 
benign  or  as  malignant. 

The  benign  neoplasms  are  those  that  arise  primarily 
within  the  wall  of  the  viscus  and  confine  their  growth  to  the 
stomach.  It  is  rare  for  them  to  invade  adjacent  viscera  by 
contiguous  extension  or  by  metastases  through  blood-  or 
lymph-channels.  They  are  generally  of  relatively  slow 
growth,  but  may  bring  about  death  of  their  host.  The 
fatal  termination  most  commonly  ensues  from  the  pro- 
duction of  various  types  of  stenoses.  Starvation  and 
malnutrition  then  result.  Tumors  of  this  type  are  myo- 
mata,  fibromata,  papillomata,  syphilomata,  tuberculomata, 
lipomata,  cysts,  osteomata,  myxomata  and  aneurysms. 

Malignant  gastric  neoplasms  most  frequently  arise  at 
some  part  of  the  gastric  wall.  They  may,  however, 
secondarily  involve  the  stomach  as  a  consequence  of 
metastasis  from  an  extragastric  tumor  (uterus,  liver,  breast, 
etc.).  This  group  includes  carcinomata  and  sarcomata. 
Clinically,  both  may  be  styled  cancer.  These  tumors  are 
malignant  in  the  sense  that  they  are  progressive  in  growth, 
bring  about  destruction  of  normal  tissue,  produce  useless 
malformations  of  the  viscus,  often  involve  adjacent 
organs  by  direct  extension  or  distant  organs  by  metastases, 
and,  if  not  disturbed,  generally  cause  death  of  the  individual 
by  that  metabolic  derangement  whose  consequences  we  rec- 
ognize as  cachexia. 

51 


52  CANCER    OF    THE    STOMACH 

Of  the  malignant  gastric  tumors,  sarcoma  is  of  rare 
occurrence.  The  first  authentic  example  was  described 
by  Virchow.  Since  then  an  occasional  specimen  has  been 
mentioned  in  the  literature.  Eleven  years  ago  the  Fenwicks 
estimated  that  sarcomata  constitute  more  than  5  per  cent, 
of  all  primary  neoplasms  of  the  stomach.  Interesting 
summaries  of  the  affection  have  been  made  by  Yates, 
Clendenning,  Frazier  and  Campbell.  They  are  infre- 
quently diagnosed  before  laparotomy  or  necropsy,  inas- 
much as  symptomatically  they  resemble  carcinomata. 

Gastric  carcinoma — commonly  styled  ''cancer" — com- 
prises nearly  94  per  cent,  of  all  clinically  or  pathologically 
known  forms  of  neoplasm  primarily  arising  in  the  stomach 
wall.  Pathologicall}^  this  type  of  tumor  manifests  itseK 
as  a  group  of  malignant  histo-pathologic  processes.  It  is 
necessary"  to  consider  both  gross  and  77iicroscopic  deviations 
from  the  normal, 

1.  Gross  Deviations  from  the  Normal. — AMiile  the  line 
of  demarcation  between  types  of  carcinomata  of  the 
stomach  is  a  rather  indefinite  one,  the  classic  descriptions 
of  such  embodied  in  the  writings  of  Waldeyer  and  Roki- 
tansky  comprise  the  most  practical  macroscopic  classifica- 
tion of  the  disease.  These  pioneers  recognized  3  general 
forms  of  gastric  cancer.  We  have  added  a  fourth  group. 
The  following  classification  is  adopted  from  their  descrip- 
tions : 

(a)  Fibrous  cancer;  scirrhus;  carcinoma  fibrosum.  Usu- 
ally a  dense,  well-delimited,  poorly  vascularized  growth, 
generally  forming  circumscribed  nodules,  or  arranged  as  a 
tumor  of  annular  ty^Q.  The  stomach- wall  is  thickened, 
stiffened  and  puckered.  Nodules  project  into  its  lumen. 
The  tendency  to  ulceration  is  not  great.  The  growth^can 
be  moderately  well  outlined  by  the  fingers.     It  is  firm  and 


MORBID    ANATOMY 


53 


unyielding  to  the  touch  until  secondary  changes  have  taken 
place. 

(6)  Medullary  cancer;  ''fleshy,"  ''cauliflower,"  cellular 
and  vascular  type;  carcinoma  medullare.  Essentially  a 
rapidly  growing  tumor  primarily  of  the  structures  of  the 
mucosa  and  submucosa.  This  results  in  soft,  nodular 
protuberances  which  invade  the  lumen  of  the  stomach, 


Fig.  1. — (Case  No.  21,559). — Primary  carcinoma  involving  the  pyloric 
third,  scirrhus  type,  pyloric  obstruction.  Great  thickening  of  gastric  wall, 
gland  involvement,  free  fluid  in  abdomen.  Specimen  obtained  at 
laparotomy. — (Courtesy  of  Mayo  Clinic.) 


spread  rapidly  and  ulcerate  early.  The  actively  proliferat- 
ing cancer  cells  quickly  penetrate  all  layers  of  the  stomach- 
wall;  vascularization  is  generally  free;  adjacent  organs  are 
invaded  by  continuity  or  lymph  and  blood-stream  metas- 
tases; perigastric  lymph  glands  harbor  the  growth  and 
distant  organs  early  suffer  malignant  change.  This  cellular 
and  vascular  type  of  growth  renders  both  primary  and 
secondary  tumors  soft  to  the  palpating  fingers. 


54  CANCER    OF    THE    STOMACH 

(c)  Ulcerating  cancer;  ulcus  carcinomatosum.  This  may 
result  from  cancerous  change  in  a  pre-existing  calloused 
ulcer,  or  may  occur  from  the  secondary  ulceration  and 
sloughing  of  carcinoma  medullare  or  carcinoma  fibrosum. 
At  laparotomy  this  type  is  of  most  common  occurrence. 
The  growth  may  be  but  1  cm.  in  diameter,  but  may  in- 


FiG.  2. — (Case  No.  16,636). — Cancer  of  the  pyloric  end.  Clinically 
scirrhus  type.  Great  thickening  of  stomach  wall,  multiple  nodules,  peri- 
gastric gland  involvement.  No  history  of  antecedent  dyspeptic  disturbance. 
Specimen  obtained  at  laparotomy. — (Courtesy  of  Mayo  Clinic.) 


volve  as  much  as  a  fourth  of  the  viscus.  Its  base  is 
commonly  firm.  Its  edges  are  not  infrequently  soft, 
ragged,  vascular  and  undermined  (but  may  be  smooth  and 
shiny).  The  process  is  often  well  deUmited.  Malignant 
perigastric  lymphatic  gland  enlargements  are  common. 
Metastases  out  of  all  proportion  to  the  size  of  the  local 


MORBID   ANATOMY 


55 


Fig.  3. — (Case  No.  16,186).— Primary  carcinoma  involving  pyloric 
end  of  stomach.  Medullary  type  with  numerous  points  of  ulceration. 
Extensive  infiltration  of  gastric  wall.  Specimen  obtained  at  laparotomy. — 
(Courtesy  of  Mayo  Clinic.) 


Fig.  4. — (Case  No.  16,765). — Multiple  gastric  carcinoma  of  the  medul- 
lary type,  involving  pyloric  third  of  stomach.  Numerous  nodules  and  points 
of  surface  ulceration.  Thickening  of  gastric  wall,  perigastric  gland  involve- 
ment.    Specimen  obtained  at  laparotomy. — (Courtesy  of  Mayo  Clinic.) 


56 


CANCER   OF   THE    STOMACH 


Fig.  5. — (Case  No.  15,694). — Large  carcinoma  of  the  medullary-scirrhus 
type  involving  the  pyloric  third  of  the  stomach.  Enormous  infiltration  and 
hyperplasia  of  stomach  walls;  superficial  erosions;  pyloric  obstruction. 
Patient  had  precarcinomatous  history,  clinically  that  of  peptic  ulcer. 
Specimen  obtained  at  laparotomy. — (Courtesy  of  Mayo  Clinic.) 


MOKBID   ANATOMY 


57 


Fig.  6. — (Case  No.  14,897). — Large  carcinoma  of  the  posterior  wall  and 
pyloric  end  of  the  stomach;  meduUary-scirrhus  type;  extensive  invasion  of 
the  gastric  wall;  superficial  necrosis,  sloughing  and  hemorrhage;  pyloric 
obstruction.  Patient  had  precarcinomatous  history,  clinically  that  of 
peptic  ulcer.  Specimen  obtained  at  laparotomy. — (Courtesy  of  Mayo 
Clinic.) 


58 


CANCER    OF    THE    STOMACH 


gastric  process  may  be  discovered  in  adjacent  glands  or 
organs. 

(d)  Colloid  cancer;  gelatinous  cancer,  mucoid  cancer; 
carcinoma  colloides.  The  diffusely  infiltrating  type,  which, 
due  to  mucoid  degeneration  of  the  cells  composing  it,  as 
well  as  to  their  excretion  of  a  substance  resembling  clouded 


Fig.  7. — (Case  No.  14,849). — Carcinoma  involving  the  pylorus  and  lesser 
curvature.  Extensive  tumor  of  the  meduUary-scirrhus  type  with  small 
areas_  of  colloid  degeneration.  Enormous  infiltration  of  stomach  wall, 
pyloric  obstruction ;  perigastric  gland  invasion.  Patient  had  precarcinomat- 
ous history,  clinically  that  of  peptic  ulcer.  Specimen  obtained  at 
laparotomy. — (Courtesy  of  Mayo  Clinic.) 


egg-white,  presents  a  water  logged,  translucent,  jelly-like 
appearance.  It  ulcerates  rarely,  spreads  extensively,  and 
may  form  metastases.  It  is  the  least  frequent  type  of 
gastric  cancer  (excluding  sarcoma). 

2.  Histologic  Deviations  from  the  Normal. — While  the 
above  macroscopic  classification  of  gastric  cancer  is  a  prac- 
tical clinical  grouping,  it  must  not  be  supposed  that  the 


MORBID    AXATOMY 


59 


Fig.  8. — (Case  Xo.  14,727). — Extensive  primary  carcinoma  of  the  medul- 
lar j^-scirrhus  type  involving  pyloric  half  of  stomach;  enormous  thickening 
of  stomach  wall;  pyloric  obstruction;  small  gastric  lumen  ("leather-bottle 
type") ;  perigastric  gland  involvement.  Specimen  obtained  at  laparotomy. — 
(Courtesy  of  Mayo  Clinic.) 


60 


CANCER   OF   THE    STOMACH 


Fig.  9. — (Case  No.  20,468). — Ring  cancer  of  the  medullary-scirrhus 
type  involving  the  pylorus;  moderate  hyperplasia  of  the  stomach  wall; 
superficial  ulceration;  perigastric  gland  involvement.  Patient  had  pre- 
carcinomatous history,  clinically  that  of  peptic  ulcer.  Specimen  obtained 
at  laparotomy. — (Courtesy  of  Mayo  Clinic.) 


MORBID    ANATOMY 


61 


Fig.  10. — (Case  No.  22,314). — Carcinoma  of  the  scirrhus  type  involving 
the  pyloric  half  of  the  stomach;  enormous  hyperplasia  of  gastric  wall; 
pyloric  stenosis;  small  gastric  lumen  ("leather-bottle  type").  Specimen 
obtained  at  laparotomy. — (Courtesy  of  Mayo  Clinic.) 


62 


CANCER    OF    THE    STOMACH 


Fig.  11. — (Case  No.  14,959). — Ring  carcinoma  of  the  scirrhus  type  involv- 
ing the  pylorus  and  antrum;  extensive  infiltration  of  stomach  wall;  pyloric 
obstruction.  Patient  had  precarcinomatous  history,  clinically  that  of 
peptic  ulcer.  Specimen  obtained  at  laparotomy. — (Courtesy  of  Mayo 
Clinic.) 


MORBID    ANATOMY 


63 


Fig.  12. — (Case  No.  19,921). — Extensive  carcinoma  of  the  medullary- 
type  involving  pyloric  third  of  stomach;  moderate  pyloric  obstruction; 
areas  showing  necrosis,  sloughing  and  hemorrhage;  moderate  invasion  of  the 
gastric  wall.  Patient  had  precarcinomatous  history,  clinically  that  of 
peptic  ulcer.  Specimen  obtained  at  laparotomy. — (Courtesy  of  Mayo 
Clinic.) 


64 


CANCEE    OF   THE    STOMACH 


Fig.  13. — (Case  No.  16,426j. — Large  medullary  carcinoma  of  the  papil- 
lomatous type;  superficial  erosions;  enormous  hyperplasia  and  infiltration 
of  the  gastric  wall.  Patient  had  precarcinomatous  history,  clinically  that 
of  peptic  ulcer.  Specimen  obtained  at  laparotomy. — (Courtesy  of  ^Slayo 
Clinic.) 


Fig.  14. — (Case  Xo.  19,832). — Medullary  carcinoma  involving  the  py- 
lorus; enormous  hj'perplasia  of  gastric  wall;  pyloric  obstruction;  secoiidary 
ulceration  of  tumor.  Patient  had  a  precarcinomatous  history,  clinically 
that  of  peptic  ulcer.  Specimen  obtained  at  laparotomy. — (Courtesy  of 
Mayo  Clinic.) 


MORBID   ANATOMY 


65 


Fig.  15. — (Case  No.  21,803). — Ring  carcinoma  of  the  medullary  type 
involving  pyloric  end  of  stomach.  Patient  had  precarcinomatous  history 
of  the  peptic  ulcer  type.  Specimen  shows  canalization  of  tumor  obstruct- 
ing pylorus;  enormous  hyperplasia  of  stomach  wall;  perigastric  gland  in- 
volvement. Specimen  obtained  at  laparotomy. — -(Courtesy  of  Mayo 
Clinic.) 


Fig.  16. — (Case  No.  21,873). — Ring  carcinoma  involving  the  pylorus; 
superficial  erosions;  great  hyperplasia  of  gastric  wall,  locally;  pyloric 
obstruction;  perigastric  gland  involvement.  Patient  had  precarcinomat- 
ous history  clinically  that  of  peptic  ulcer.  Specimen  removed  at 
laparotomy. — (Courtesy  of  Mayo  Clinic.) 


66 


CANCER   OF   THE    STOMACH 


Fig.   17. — (Case  No.  21,555). — Stereogram  showing  carcinoma  associated 
with  a  large  ulcer  of  the  lesser  curvature. — (Wilson  and  MacCarty.) 


MORBID    AXATOMY 


67 


I 


/li 


Fig.  is. — (Case  No.  21,oo5). — Photomicrogram  from  the  edge  of  tlie 
ulcer,  bases  of  tubular  glands  show  early  carcinomatous  change  (X  100). — 
(Wilson  and  MacCarty.) 


;r:!afi| 


Fig.  19. — (Case  No.  21,555;. — Pliotuiuicrugr^iai  oi  a_  section_  of  the 
base  of  the  ulcer,  showing  scirrhus  cancer  (X  100). — (Wilson  and  Mac- 
Carty.) 


68 


CANCER    OF    THE    STOMACH 


^  f,?  -^ 


'     ,4.'' 


v.  * 


Fig.  20. — (Case  No.  21,555). — Islands  of  carcinoma  in  the 
submucosa. — (MacCarty.) 


Fig.  21. — (Case  No.  21,555). — ^Irregularly  shaped  epithelial  cells  near  the 
muscularis  mucosae. — (MacCarty.) 


MOEBID    ANATOMY 


69 


Fig.  22. — (Case  No.  15,681). — Stereogram  of  a  portion  of  the  pyloric 
half  of  the  stomach,  showing  carcinoma  involving  the  lesser  curvature  and 
the  pylorus. — (Wilson  and  MacCarty.) 


WM^^^iM 


Fig.  23. — (Case  No.  15,681). — Photomicrogram  showing  hyperplastic 
epithelium  in  the  swollen  mucosa  of  the  edge  of  the  ulcer  (X  100). — 
(Wilson  and  MacCarty.) 


70 


CANCER    OF    THE    STOMACH 


Fig.  21. — (Case  No.  15,681). — Photomicrogram  showing  atypical   epithe- 
lial proliferation  (X  100). — (Wilson  and  MacCarty.) 


^.-V-^-t:..' 


',    ^.^'t^--   *• 


Fig.  25. — (Case    No.    15,681). — Photomicrogram   from    the    base   of   the 
malignant  ulcer  (X  100). — (Wilson  and  MacCarty.) 


MORBID   ANATOMY 


71 


Fig.  26. — (Case  No.  18,867). — Stereogram  of  the  lesser  curvature,  show- 
ing proliferation  of  the  muscularis  associated  with  ulcus  carcinomatosum. — • 
(Wilson  and  MacCarty.) 


Fig.  27.— (Case  No.  18,867).— Photomicrogram  of  epithelial  cells  par- 
tially cut  off  from  the  surface,  actively  proliferating  but  not  infiltrating  the 
surrounding  tissues  (X  100). — (Wilson  and  MacCarty.) 


72 


CANCER    OF    THE    STOMACH 


Fig.  28. — (Case  No.  18,867). — Photomicrogram    showing  area  of  typica 
carcinomatous  tissue  (X  100). —  (Wilson   and  MacCarty.) 


Fig.  29. — (Case  No.  16,525). — Stereogram  of  the  pjdoric  two-thirds  of 
the  stomach;  carcinomatous  ulcer  beginning  on  the  lesser  curvature. — (Wil- 
son and  MacCarty.) 


MORBID    ANATOMY 


73 


Fig.  30. — (Case  No.  16,525). — Photomicrogram  showing  areas  of  scirrhus 
carcinoma  (X  100). — (Wilson  and  MacCarty.) 


Fig.  31. — (Case  Xo.  16,525). — Photomicrogram  showing  a  cross-section 
of  the  hyperplastic  epithelial  elements  with  round-cell  infiltration  between 
the  gland  tubules  (X  100). — (Wilson  and  MacCarty.) 


74 


CANCER    OF    THE    STOMACH 


Fig.  32. — (Case  No.  16,525). — Photomicrogram  showing  the  bases  of  the 
glands  clipped  off  by  scar  tissue  (X  100). — (Wilson  and  MacCarty.) 


'^ 


Fig.  33. — (Case  No.  16,525). — Photomicrogram  showing  active  malig- 
nant proliferation  with  much  round-cell  infiltration  (X  100). — (Wils(m 
and  MacCarty.) 


MORBID    ANATOMY 


75 


Fig.  34. — (Case   No.    18,088). — Stereogram  of  the  pyloric  third  of  the 
stomach;  multiple  ulcers  of  malignant  type. — (Wilson  and  MacCarty.) 


Fig.    35. — (Case  No.  18,088). — Photomicrograph  of  the  overhanging  ulcer 
border  (X  100).— (Wilson  and  MacCarty.) 


76 


CANCER    OF   THE    STOMACH 


Fig.  36. — (Case  No.  18,088). — Photomicrograph  from  submucosa  showing 
aberrant  proliferation  and  infiltration  (X  100). — (Wilson  and  AlacCarty.) 


MORBID    AXATOMY 


77 


-5  >, 
II 

-8 


5  3 


e  ^ 


Q 


78 


CANCER   OF   THE    STOMACH 


Fig.  38. — (Case  No.  15,235). — Ulcus  carcinomatosum  of  the  antrum. 
Ulcer  has  smooth  terraced  borders  and  is  surrounded  by  actively  proliferat- 
ing carcinoma  of  the  medullary  type.  Enormous  infiltration  and  hyper- 
plasia of  gastric  wall.  Patient  had  precarcinomatous  history,  clinically 
that  of  peptic  ulcer.  Specimen  obtained  at  laparotomy. — (Courtesy  of 
Mayo  Clinic.) 


MORBID    ANATOMY  79 

types  described  include  definite  and  single  histologic 
entities.  It  should  be  emphasized  that  all  gastric  cancers 
have  in  and  about  them  histologic  changes  demonstrating 
attempts  at  resistance  and  repair  on  the  part  of  the  in- 
vaded tissues.  Consequently,  it  is  possible  to  define 
scirrhus,  medullary,  ulcerating,  or  even  colloid  areas, 
locally,  in  the  majority  of  growths,  where  the  process  has 
existed  for  a  considerable  time.  This  is  especially  the  case 
when  specimens  are  examined  from  necropsies.  Growths 
received  from  laparotomies  contain  fewer  examples  of 
retrograde  changes.  The  latter  type  furnishes  the  most 
satisfactory  material  upon  which  to  study  cancer  invasion 
and  from  which  to  offer  a  classification  of  the  disease  from 
the  histologic  standpoint. 

Various  histologic  groupings  of  gastric  carcinomata 
have  been  advanced.  Most  of  them  are  artificial,  in- 
complete, confusing  and  unnecessary. 

Inasmuch  as  carcinoma  is  an  atypical  epitheUal  neo- 
plasm (Waldeyer),  and  inasmuch  as  in  the  stomach,  the 
neoplasm  originates  from  the  cylindrical  epithelia  making 
up  the  glands  of  the  mucosa,  it  is  evident  that  but  few  ele- 
mentary factors  can  enter  into  the  histopathologic  picture 
presented  by  its  development.  The  facts  to  be  con- 
sidered are:  (a)  the  abnormal  proliferation  of  gland 
cells;  (6)  the  rate  of  their  growth;  (c)  the  direction  of 
that  growth;  {d)  the  reaction  of  adjacent  tissue  to  the 
presence  of  atypically  proliferating  and  physiologically 
undifferentiated  epithelium;  and  (e)  retrograde  changes 
in  either  epithelia  or  connective  tissue  or  both. 

THE  ABNORMAL  PROLIFERATION  OF  GLAND  CELLS 

No  one  has  ever  observed  the  earliest  beginnings  of 
any    malignant    process,    histologically,    in    the  human. 


80  CANCER    OF    THE    STOMACH 

No  one  has  ever  experimentally  produced  a  cancer  in  a 
human  being,  hence  it  is  impossible  to  say  just  what  intra- 
cellular change  of  what  primary  intracellular  fault  con- 
stitutes the  beginnings  of  malignancy.  The  large  ma- 
jority of  histologic  descriptions  of  malignancy,  particularly 
of  gastric  cancer,  are  not  those  where  the  disease  is  in  its 
inception,  but  are  views  of  a  pathologic  process  well  under 
way.  This  fact  is  to  be  strongly  emphasized  with  respect 
to  those  histopathologic  reports  from  necropsies  where 
patients  have  succumbed  to  gastric  cancer.  In  such 
beginning  cellular  change  cannot  be  described.  The 
cellular  battle  is  largely  over.  The  primary  disposition  of 
the  warring  forces  is  a  histologic  secret.  Unfortunately 
such  end-results  were  painstakingly  described  nearly  a 
half  century  ago,  and  have  become  rooted  in  the  general 
mind  and  form  much  of  the  pathologic  conception  of  the 
disease,  whereas  they  only  constitute  the  least  interesting 
phase  of  it,  namely,  the  end-result.  From  the  viewpoint 
of  cancer  prophylaxis,  their  chief  value  lies  in  pointing  out 
the  moral — to  emphasize  the  consequences  of  tumor  growth. 
It  is  now  generally  accepted  that  early  malignant  proc- 
esses are  in  the  nature  of  hyperplasia  of  already  existing 
structural  elements.  Through  some  intracellular  devia- 
tion from  the  normal,  a  tissue  reaction  takes  place  which 
results  in  undifferentiated  growth  of  a  particular  cell 
group.  In  the  majority  of  instances  the  initial  structure 
of  the  part  affected  is  reproduced,  but  commonly  the 
specific  function  of  the  cells  making  up  that  structure  is 
lost.  Thus,  so  far  as  our  knowledge  extends,  the  earliest 
evidences  of  gastric  malignancy  occur  in  what  were  pre- 
viously normal  cells  lining  gland  tubules.  At  this  stage  of 
the  process,  there  is  as  yet  very  little,  if  any,  recognizable 
periglandular  tissue  reaction. 


MORBID   ANATOMY  81 

Just  what  causes  this  intracellular  fault  in  the  cells 
involved,  we  are  not  at  present  able  to  state.  It  may  be 
reaction  to  any  irritant  or  group  of  irritants.  These 
irritants  may  be  chemical,  biochemical,  mechanical  or 
parasitic.  It  would  appear  that  in  addition  to  the  presence 
of  cellular  irritants  one  must  consider  the  possibilities 
of  an  inborn  or  acquired  susceptibility  on  the  part  of  an 
individual  cell,  or  a  group  of  cells,  to  a  metabolic  upset 
from  such  source.  Certainly,  the  same  types  of  trau- 
matic agents,  offered  to  like  tissue  in  different  hosts,  cause 
widely  varying  cell  reactions. 

Certain  experimental  evidence  tends  to  support  the 
above  general  description  of  the  earliest  phase  of  malig- 
nancy. At  this  stage  rarely  is  a  microscopic  picture  pre- 
sented, nor  is  it  proper  to  term  the  early  intracellular  change 
a  precancerous  lesion.  There  would  seem  to  be  abundant 
proof  that  not  infrequently  similar  early  alterations  occm- 
in  cell-groups  and  yet  do  not  progress  to  malignancy.  To 
Rous  and  Murphy  we  are  indebted  for  our  microscopic 
conception  of  slightly  developed  neoplasms.  Working 
with  a  chicken  sarcoma  implanted  in  developing  chick 
embryos,  they  noted  that  first,  the  transplant  occurred 
along  the  line  of  the  tissue  which  had  been  injured  by  the 
inoculating  needle.  After  16  days  this  growth  was  well 
defined  and  had  the  appearance  of  scar-tissue.  Vas- 
cularization took  place  in  4  days  and  shortly  later  than  when 
the  appearance  of  secondary  nodules  had  occurred  along 
the  line  of  the  vessels.  Microscopically,  very  actively 
proHferating  cells  were  seen  enclosed  in  a  loose  mesh-work 
of  supporting  tissue.  The  early  sarcomatous  cells  appeared 
larger  than  those  of  normal  connective-tissue  elements. 
That  there  seemed  to  be  a  definite  intracellular  difference 
was  demonstrated  by  the  fact  that  the  cytoplasm  stained 


82  CANCER    OF   THE    STOMACH 

much  more  deeply  with  methylene  blue  than  did  that 
in  normal  cells.  Nuclei  were  large,  oval  or  elongated  or 
vesicular.  They  contained  a  fine  chromatin  network 
and  had  a  well-defined,  deeply  staining  nucleolus.  Pro- 
liferation was  extremely  active,  as  many  as  69  per  cent,  of 
the  cells  being  noted  in  various  stages  of  division  at  one 
time.  The  growth  took  place  mainly  by  amitosis.  In 
the  surrounding  tissue  the  first  influences  of  growth  were 
those  occurring  as  result  of  simple  pressure.  The  neoplasm 
developed  along  the  line  of  least  resistance  and  metastases 
took  place  through  the  lymph  spaces.  Very  early  there 
developed  about  the  growing  tumor  fragment  a  moderate 
amount  of  edema  and  exudation.  Polymorphonuclear 
cells  appeared  coihcidentally.  These  were  soon  replaced 
by  a  small  round-cell  lymphocyte  infiltration  which  usually 
became  most  marked  where  the  invading  cells  were  in 
actual  contact  with  the  cells  of  the  host.  This  was  followed 
by  the  appearance  of  fibroblasts,  macrophages  and  newly 
formed  capillaries  at  these  points.  A  few  giant  cells  often 
appeared.  Sometimes  the  vascularization  was  tardy  and 
before  it  occurred  the  tumor  cells  had  invaded  the  tissue 
of  the  host  at  the  points  of  contact  with  it.  The  growth 
proved  to  be  most  rapid  along  the  normal  blood-vessels 
and  the  connective  tissue  already  present.  At  the  advanc- 
ing margin  there  was  not  the  tissue  reaction  as  is  seen  in 
inflammation.  Lymphocytes  were  few  and  often  practi- 
cally absent.  Of  course,  these  investigators  were  dealing 
with  embryos  and  in  them  few  protective  bodies  had  as 
yet  been  developed.  When  this  histologic  picture  was 
presented  the  transplanted  growth  might  be  considered 
well  established.  The  resultant  great  tumor  was  made 
up  of  accumulations  of  cells  similar  to  the  few  which 
originated  the  process.     Vascularization  and  progressive 


MORBID   ANATOMY  83 

changes  resulted.  If,  however,  the  host  was  not  suscep- 
tible or  there  were  some  factors  in  resistance  which  are 
not  as  yet  understood,  retrograde  changes  occurred  and 
the  initial  tumor  soon  disappeared. 

Working  with  an  adenocarcinoma  of  the  white  rat  de- 
scribed by  Flexner  and  Jobling,  Levin  claims  to  have  pro- 
duced certain  local  tissue  reactions  in  non-susceptible 
animals  which,  later  on,  permitted  the  transplantation  of 
a  neoplasm.  In  other  words,  by  chemical  or  mechanical 
means,  or  both,  he  claims  to  have  so  altered  the  inherent 
cellular  resistance  of  tissue  as  to  bring  about  a  so-called 
''precancerous"  state  which  later  on  permitted  the 
growth  of  an  implanted  tumor.  Levin  injected  into  the 
testicle  of  a  rabbit  2  or  3  minims  of  Scharlach  R- 
oil.  These  injections  produced  a  local  tissue  reaction 
simulating  simple  inflammatory  hyperemia.  There  may 
have  been  some  other  local  fault.  When  placed  into  this 
inflamed  and  hyerplastic  tissue,  tumors  developed  in  a 
considerable  proportion  of  instances.  That  the  injection 
of  the  irritant  does  not  itself  produce  anything  more  than  a 
granulomatous  tumor  has  been  shown  by  the  experiments 
of  Snow. 

Recently,  Erwin  Smith  has  shown  that  if  plant  cells 
are  submitted  to  a  local  irritant,  cancer-hke  growths 
result.  Working  with  a  bacillus  isolated  from  galls  of  a 
daisy,  he  has  succeeded  in  producing  at  will  similar  tumors 
in  such  plants.  The  bacillus  is  known  as  Bacterium 
tumefaciens.  If  healthy  plants  are  inoculated  with  this 
organism,  rapidly  developing  growths  result  which  even- 
tually destroy  the  plant.  Other  plants  are  also  susceptible. 
Certain  metastasis-like  secondary  growths  develop  from 
the  primary  tumor.  While  many  of  the  tumors  described 
by  Smith  are  of  the  granulomatous  type,  it  would  seem  that 


84  CANCER   OF   THE    STOMACH 

his  experiments  are  not  without  value  as  showing  in  what 
manner  normal  tissue  reacts  to  a  constantly  multiplying 
irritant.  The  reaction  is  essentially  one  of  hyperplasia 
of  certain  cell  groups.  Not  infrequently  it  is  impossible 
to  state  where  benign  hyperplasia  ends  and  malignant 
hyperplasia  begins. 

With  regard  to  the  experimental  production  of  gastric 
can(}er  in  animals,  few  facts  are  available.  The  most  strik- 
ing investigations  are  those  of  Fibiger  of  Copenhagen. 
This  investigator  noted  that  not  infrequently  certain  labo- 
ratory rats  died  as  the  result  of  cancer-Uke  tumors 
developing  in  their  stomachs.  On  investigating  some  of 
these  tumors,  he  discovered  that  while  they  were  histologic- 
ally carcinoma-like  many  of  them  contained  cysts  in  which 
were  lodged  nematodes.  Further  investigations  disclosed 
that  these  rats  fed  upon  roaches  which  infested  a  certain 
sugar  refinery  from  which  the  majority  of  the  laboratory 
rats  were  obtained.  These  roaches  on  examination  were 
found  to  be  infested  with  nematodes.  Fibiger  then  col- 
lected a  large  number  of  these  roaches  and  fed  them  to 
non-infected  laboratory  rats.  In  the  stomachs  of  many 
of  these,  carcinoma-like  growths  developed.  "V\niile  there 
is  some  doubt  of  the  true  carcinomatous  nature  of  Fibiger' s 
rat  tumors,  the  investigation  is  of  value  in  showing  the 
reaction  of  gastric  mucosa  to  a  parasitic  irritant.  It  also 
shows  the  histologic  dijOGiculty  of  differentiating  hyperplasia 
of  a  granulomatous  type  from  the  hyperplasia  of  true 
malignancy.  It  is  quite  conceivable  that  the  ingestion  of 
such  food  as  roaches  acted  as  traumata  to  the  gastric 
lining,  and  furnished  a  locus  minoris  resistentics,  at  which 
point  the  nematode  could  act  mechanically,  could  bring 
about  hyperplasia  as  result  of  undetermined  infection  of 


MORBID   ANATOMY  85 

this  parasite  itself,  or  as  a  consequence  of  a  chemical 
excretion,  secretion  or  ferment. 

To  the  painstaking  and  brilliant  work  of  MacCarty,  we 
owe  practically  all  our  useful  knowledge  regarding  the 
early  histologic  changes  which  are  associated  with  the 
development  of  gastric  cancer.  This  investigator  has 
patiently  studied  the  microscopic  deviations  from  the 
normal  of  gastric  ulcers  and  gastric  cancers  obtained  at 
laparotomy.  His  observations  are  of  particular  worth, 
because  they  cover  an  experience  extending  over  many 
years  in  handhng  the  largest  number  of  specimens  ever 
recorded;  are  upon  fresh,  and  not  dead-house,  material; 
include  both  gross  and  microscopic  studies  (the  latter 
with  oil  immersion  ampUfication) ;  have  been  carried  on 
in  a  uniform  manner  and  checked  by  comparative  photo- 
graphs and  the  clinical  courses  of  the  affected  patients. 
It  is  to  be  expected  that  MacCarty's  results  are  as  yet  not 
generally  appreciated.  They  are  too  highly  specialized 
to  come  within  the  understanding  of  the  pathologist  with 
ordinary  material  for  study  because  they  are  based  upon 
a  vast  material  and  comprise  a  histopathology  essentially 
cellular.  They  bear  a  similar  relation  to  routine  pathologic 
investigations  that  such  maintain  toward  hand  glass  or 
gross  pathology.  It  is  significant  that  the  intracellular 
deviations  and  the  intercellular  faults  described  by  Mac- 
Carty are  generally  comparable  to  such  recognized  by  re- 
search workers  engaged  in  tumor  implantation  (Rous, 
Murphy,   Gay)   or  cell  culture  studies  (Carrel). 

MacCarty  has  shown  that  in  gastric  ulcer  two  basic  his- 
tologic processes  are  in  evidence: 

(a)  Hyperplasia  of  the  elements  of  the  gastric  mu- 
cosa and  (6)  hyperplasia  of  adjacent  tissue;  (2)  retrograde 
changes  in  both  locations. 


86  CANCER   OF   THE    STOMACH 

1.  Hyperplasia. — (a)  This  occurs  in  the  gland  structures 
of  the  ulcer  edges  or  those  lying  superficial  or  deep  in  the 
submucosa. 

Such  exuberant  growth  manifests  itself  by  both  cellular 
and  intracellular  change.  The  cellular  change  consists  in 
multiplication  of  cylindrical  cells  in  the  stratum  germina- 
tivum.  The  cells  assume  vegetative  qualities  rather  than 
specific  function.     At  first  the  overgrowth  is  confined  to 


Fig.  39. —  (,'  :!-•    A".  27,919). — >t  i  uim  through  a  portion  of  the  border  of  a 
benign  chronic  peptic  ulcer. — (MacCarty.) 

the  primary  cell  layer.  The  individual  cells  increase  in 
number,  swell  and  often  stain  abnormally  with  methylene 
blue  or  hematoxylin  and  eosin.  The  process  may  stop 
here.  If  not,  the  next  step  consists  of  such  definite  hyper- 
plasia as  to  result  in  the  appearance  of  an  inner,  secondary 
layer  of  cells  arising  from  rapidly  multiplying  cells  of  the 
basal  layer.  These,  in  turn,  may  be  succeeded  by  such 
increase  in  cells  as  to  completely  fill  the  space  formerly 
held  as  a  gland  lumen.     Variations  in  cell  shape  and  size 


MORBID    ANATOMY  87 

appear,  perhaps,  as  a  consequence  of  some  altered,  in- 
tercellular relation  (Fig.  37).  Thus  far  the  process  is 
adenomatoid. 

Depending  upon  the  directions  in  which  histologic 
sections  are  cut,  and  their  location  with  respect  to  mucosa 
and  submucosa,  isolated  areas  (''cell  inclusions,"  often 
so-called)  or  filled  gland-tubules  may  be  described.  Thus 
far  there  has  been  no  alteration  in  the  relation  of  the  basal 
layer  of  cells  to  the  surrounding  structures.     The  hyper- 


*    <> 

ii 

'^^ . 

' 

i^ 

Fig.  40. — (Cas-e    Xo.    30,0-iO). — Photomicrogram  showing  hyperplasia  in 
the  mucosa  at  the  border  of  a  peptic  ulcer. — (MacCarty.) 

plastic  gland  elements  are  well  delimited.  After  the  second 
gland-cell  layer  has  developed  the  study  of  intracellular 
change  reveals  important  variations  from  the  normal. 
They  must  be  looked  for  with  oil-immersion  objective. 
The  individual  cells  vary  much  in  size  and  form,  while 
the  basal  layer  remains  cjdindrical,  cuboid  or  flattened. 
The  secondarily  developing  layers  may  be  oblong,  oval, 
rhomboid,  rounded  or  irregular.  The  whole  gland  is 
often  distended  and  distorted.  At  this  time  distinct  nu- 
clear changes  are  visible  (Figs.  21,  42  etseq.).     Nuclear  hy- 


88  CANCER   OF   THE    STOMACH 

pertrophy  occurs.  This  is  associated  with  structural  altera- 
tions in  the  nuclei  themselves.  Their  increase  in  size  is 
noticeable.  Whereas,  in  normal  gland  cells,  the  relative 
proportion  between  nucleus  and  cytoplasm  is  approximately 
as  1 : 3  or  1 : 4,  increase  in  the  nucleus  occurs  to  such  extent 
that  practically  it  may  equal  in  volume  the  cytoplasm.  A 
striking  phenomenon  is  that  of  great  variation  in  size,  shape 
and  staining  reaction  of  these  nuclei.     In  place  of  dense  nuclei 


k 


mm-T 


Fig.  41. — (Case  Xo.  27,919). — Photomicrogram  of  a  portion  of  the 
border  of  a  malignant  peptic  ulcer  showing  islands  of  carcinoma  in  the 
submucosa. — (MacCarty.) 

staining  deeply  with  Unna's  polj^chrome  blue  or  with  hema- 
toxylin, the  nuclei  stain  much  less  densely  and  are  poorly 
differentiated  structurally.  If  the  biochemical  alterations 
associated  with  the  gland  hyperplasia  are  maintained,  the 
nuclei  divide  so  rapidly  as  to  render  mitotic  figures  visible. 
At  any  rate,  proliferation  appears  accelerated.  At  this 
phase,  the  mass  of  hyperplastic  cells  may  readily  simulate 
adenoma.  The  most  marked  change  occurs  at  the  ulcer 
borders. 


MORBID   ANATOMY 


89 


It  would  appear  that  the  Hne  of  demarcation  between 
simple  hyperplasia  and  a  malignant  type  of  the  same  process 
is  very  indefinite  at  this  stage.  If  the  stimulation  to  the 
outgrowth  is  not  stopped,  however,  the  succeeding  his- 
tologic picture  often  reveals  alterations  in  the  basal  layer 
of  gland-cells.  At  some  point,  or  generally,  they  may 
wander  through  the  '' basement  membrane."  This  is 
the  first  actual  evidence,  histologically,  of  what  seemed  to 
be  a  simple,  progressive  hyperplasia  assuming  malignant 
characteristics.     Such  occurrence  is  most  common  where 


Fig.  42. — (Case  No.  97,051). — Densely  staining  mucin  within  columnar 
cells.     High  amplification. — (Wilson.) 

hyperplasia  is  most  active,  i.e.,  at  the  edges  of  ulcers:  the 
points  where  attempts  at  resistance  and  repair  are  being 
most  persistently  carried  on.  The  phenomena  occur  less 
strikingly  (and  often  later)  in  the  scar-tissue  forming  the 
base  of  the  ulcer-crater.  Depending  on  the  extent  of  the 
ulcerated  area,  the  severity  of  the  agent  tending  to  destroy 
tissue  and  the  ability  of  such  tissue  to  oppose  this,  small  or 
large  areas  showing  these  alterations  may  be  described 
in  the  mucosa  and  submucosa.  The  discovery  of  a  single 
gland  tubule,  where  actively  hyperplastic  cells  have  pene- 
trated beyond  the  normal  limiting  membrane,  is,  however, 


90  CANCER   OF   THE    STOMACH 

all  that  is  required  for  a  diagnosis  of  malignancy.  Previous 
to  this  malignancy  is  questionable.  The  subsequent  fate 
of  such  atypically  growing  cells  depends  upon  their  number, 
their  relative  position  in  the  gastric  wall,  their  stimulation 
to  growth,  the  rapidity  of  their  proliferation,  and  the 
degree  of  success  which  surrounding  tissues  have  in  repel- 
ling their  invasion.  There  may  be  variation  in  any  or  all  of 
these  factors.  Consequently,  the  above-described  process 
may  be  halted  at  any  stage  of  its  advance.  The  mass  of 
maUgnant  hyperplastic  epithelial  elements,  together  with 


^^"3^ 

,'■»-■ 

^  &. 

-  2 

^^^1.  1 

^^^^ 

J 

Fig.  43. — (Case  Xo.  94,647). — Photomicrogram  (high  power  amplifi- 
cation) of  section  across  a  cyst  of  a  pyloric  gland  in  early  gastric  cancer. 
Columnar  ceUs  filled  with  mucin;  crescentic  nuclei. — (Wilson.) 

surrounding  stroma,  makes  up  the  neoplasm.  Wide 
variation  in  size  is  possible.  The  relation  existing  between 
volume  of  epitheHal  cells  and  connective  tissue  determines 
the  cHnical  type  of  tumor  resulting.  It  furnishes  the  basis 
of  a  rough  histologic  grouping. 

(6)  Hyperplasia  of  the  extraglandular  structures  con- 
stitutes evidences  of  tissue  resistance.  It  is  grossly  a  local 
index  of  the  strength  of  the  stomach's  defensive  forces. 
These  may  be  vigorous  during  the  early  stages  of  the 
ulcerative  process  and  then  apparently  become  negligible, 


MORBID   ANATOMY  91 

or,  late  in  the  development  of  a  rapidly  advancing  ulcer, 
energetic  resistance  may  be  put  forth  and  the  process 
stopped. 

As  we  have  stated,  in  the  early  stages  of  simple  ulcer, 
hyperplasia  is  most  active  in  the  glands  of  the  edges.  This 
increase  causes  overhanging  borders.  There  is  fre- 
quently a  similar  hyperplasia  in  the  base.  Tissue  resistance 
is  manifested  by  an  abundant  infiltration  of  small  lympho- 
cytes. Not  infrequently  polynuclear  leucocytes  are  also 
present.     The  hyperplastic  gland  process  is  thus  well  walled 


Fig.  44. — (Case  No.  94,647). — Same   tissue  as  in   Fig.  43,  showing   cells 
freely  discharging  mucin;  spherical  nuclei. — (Wilson.) 

off.  There  is  little  evidence  of  vascularization.  Surface 
necrosis  often  keeps  pace  with  the  epithelial  hyperplasia — 
the  sloughing  thereby  giving  the  ulcer  a  characteristic 
crater-like  form.  In  instances  of  moderate  activity,  the 
gland  hyperplasia  is  checked  apparently  by  the  leucocyte 
invasion.  Hyperplasia  of  scar  tissue  then  occurs,  and 
typical,  protected,  callous  ulcer  results.  If,  however,  a 
source  of  stimulation  keeps  the  epithelial  hyperplasia 
active,  and  if  the  process  becomes  moderately  extensive, 
the   hypertrophied    gland j^ tubules    push    aside    the    con- 


92 


CANCER   OF   THE    STOMACH 


nective-tissue  cells  and  diminish  the  number  of  avenues 
along  which  protective  cells  or  fluids  may  be  conveyed  to 


Fig.  45. — (Case    53,784). — Hyperplasia   of    the  epithelial  gland  elements 
with  marked  piling  up  of  epithelium.     High  amplification. — (Wilson.) 

the  pathologic  area.  There  is,  however,  always  evidence 
of  an  active  resistance  being  carried  on  at  the  limits  of 
the  hyperplastic   epithelial   process.     As   a   consequence, 


Fig.  46. — (Case  No.  80,863). — Photomicrograph  showing  beginning 
multiplication  of  layers  of  gland  epithelium.  High  amplification. — 
(Wilson.) 

not  only  may  submucosa  show  hyperplastic  connective- 
tissue  changes,  but  such  may  be  made  out  in  the  muscularis 


MOEBID    ANATOMY  93 

and  subserosa.  The  tendency  is  everywhere  toward 
the  production  of  dense,  undifferentiated  scar  tissue. 
Deepening  of  the  ulcer  crater  by  surface  sloughing  together 
with  extension  of  rapidly  enlarging  gland  tubules  may 
accelerate  the  process  or  increase  its  extent. 

The  above  attempt  to  resist  invasion  appears  to  be 
carried  on  by  connective  tissue  concomitantly  with  epi- 
thelial increase  until  direct  intrusion  of  the  epithelial 
tissue  occurs.  After  that  essential,  histologic,  structural 
fault,  some  yet  unknown  influence  seems  to  diminish  the 
strength  of  the  connective-tissue  resistance.  This  is  shown, 
histologically,  by  diminution  of  lymphocytes  and  leuco- 
cytes, by  tendency  to  vascularization,  more  active  growth 
of  atypically  located  gland  cells  and  by  retrograde  changes 
of  tissue.  These  are  frequently  manifested  early.  When 
once  this  balance  between  tendency  of  gland  cells  to 
exuberant  growth  and  inherent  property  of  surrounding 
tissue  to  prevent  such  has  been  upset,  the  tide  of  cancer 
cells  flows  forward  seemingly  opposed  very  weakly. 

2.  Retrograde  Changes. — In  ulcerating  gastric  mucosa 
progressive  and  retrograde  changes  are  constantly  inter- 
acting. While  hyperplasia  is  yet  simple,  the  surface 
epithelium  undergoes  cloudy  swelling,  granulation,  mucoid 
degeneration  and  liquefaction  necrosis.  Microscopic  or 
gross  sloughs  result.  These  changes  form  a  part  of  the 
attempt  at  repair  which  is  being  carried  on,  and  of  which 
the  process  of  hyperplasia  of  gland  and  connective-tissue 
elements  is  a  part. 

If  the  agent  exciting  epithelial  elements  to  attempt 
normal  repair  is  not  removed,  and  the  false  metaplasia 
which  results  in  tumor  formation  ensues,  retrograde  changes 
are  manifested  in  the  neoplasm  itself.  They  are  most 
actively  carried  on  toward  the  lumen  of  the  stomach,  but 


94  CANCER   OF   THE    STOMACH 

may  be  exhibited  at  any  part  of  its  altered  wall.  These 
retrograde  changes  are  resisted  by  the  cancer  cells  just 
as  normal  epithelium  resisted  them.  The  altered  physio- 
logic units,  however,  not  infrequently  fail  to  prolong 
such  resistance.  As  a  consequence,  the  cells  at  the  surface 
of  the  neoplasm  may  rapidly  undergo  granulation,  mucoid 
or  colloid  change  and  necrosis.  The  free  vascularization 
of  the  more  cellular  types  of  growth  permits  extensive 
blood  extravasation,  cyst  formation  and  frequently  ex- 
tensive sloughing.  The  rapidity  with  which  cell  pro- 
liferation, necrosis  and  sloughing  occur  and  cause  the  death 
of  the  individual  rarely  permit  the  retrograde  changes 
going  beyond  the  colloid  stage.  Occasionally,  small  cal- 
cified areas  are  seen  in  slow-growing  tumors  located  deep 
in  the  submucosa. 

These  progressive  and  retrograde  tumor  changes  and 
the  reaction  of  surrounding  tissues  have  much  to  do  with 
the  gross  characteristics  of  gastric  tumors.  Their  evi- 
dences are  largely  responsible  for  the  common  clinical 
classification  of  such  neoplasms  into  carcinoma  medullare, 
carcinoma  fibrosum,  ulcus  carcinomatosum,  and  carcinoma 
colloides.  They  also  influence  the  histologic  picture,  so 
that  we  not  infrequently  see  such  groupings  of  the  disease 
as  spheroidal-celled  carcinoma,  cylindrical-celled  carcinoma 
(adenocarcinoma)  and  mucous-celled  (colloid)  carcinoma. 
From  the  preceding  attempt  to  explain  the  early  changes 
constituting  gastric  cancer,  it  will  be  seen  that  any  such 
classification  is  incomplete  and  misleading.  So-called 
''types"  of  carcinoma  occur  entirely  because  cancer  cells 
grow  differently  in  relation  to  connective  tissue  and  they 
are  influenced  by  both  progressive  and  retrograde  changes 
in  themselves  and  in  surrounding  tissue.  These  neo*- 
plasms   are   derived   from   gastric   gland   epithelium   and 


MOEBID   ANATOMY  95 

are  thus  essentially  of  the  same  parentage.  At  some 
stage  in  the  development  of  any  gastric  cancer,  it  is  quite 
likely  that  practically  all  so-called  ''tj^Des"  of  cells  could 
have  been  recognized  and  that  degenerative  processes 
could  have  been  seen.  The  confused  histologic  and 
gross  classifications  that  have  been  presented  are  accounted 
for  largely  because  they  have  been  based  upon  examination 
of  specimens  removed  from  patients  who  have  died  from 
the  disease.  In  comparison  we  would  mention  that  a 
full-grown  flower  rarely  resembles  its  bud  nor  yet  does  the 
bud  recall  the  seed  which  gave  both,  as  well  as  the  vine, 
their  birth. 

THE  RATE   OF   GROWTH   OF   GASTRIC   NEOPLASMS 

That  neoplasms  in  general  may  develop  with  astonishing 
rapidity  is  experimentally  shown  by  the  work  of  Rous. 
Fifteen  days  after  transplanting  minute  fragments  of 
chicken  sarcoma  into  chick  embryos,  visible  and  tangible 
tumors  were  present.  Histologically  69  per  cent,  of  the 
tumor  cells  were  shown  to  be  dividing  by  amitosis. 

In  human  gastric  cancer,  the  rate  of  growth  varies 
widely.  Those  tumors  confining  themselves  to  the  mucous 
membrane  and  the  loose  submucosa  grow  with  the  great- 
est speed.  Such  rapid  advance  occurs  most  commonly  in 
so-called  ''primary"  gastric  cancer  (without  antecedent 
ulcer,  benign  or  mahgnant).  In  such  location  connective- 
tissue  barriers  are  weak  and  few.  Clinically,  this  type 
of  tumor  may  cause  death  of  the  host,  in  our  experience, 
within  7  weeks  of  the  onset  of  symptoms.  We  have  seen 
epigastric  tumor  increase  in  size  threefold  in  rather  more 
than  a  month.  Tumors  derived  from  gland-cell  groups 
located  deep  in  the  submucosa  and  progressing  in  it  or  to- 
ward the  muscularis  increase  in  size  with  comparative  slow- 


96  CANCER   OF   THE    STOMACH 

ness.  We  have  observed  instances  where  epigastric  nod- 
ules have  existed  in  epigastria  for  more  than  a  year  and 
symptoms  for  as  long  as  3  years,  and  yet  at  laparotomy 
tumors  have  weighed  less  than  60  grams.  Epithelial 
elements  in  such  are  generally  well  spht  up  with  scar 
tissue.  Not  infrequently,  it  would  seem  that  atypically 
growing  epithelia  exist  in  the  edges  or  bases  of  ulcers 
for  many  months  without  progressing  far.  Sloughs  may 
remove  many  such  and  be  a  prophylactic  measure.  These 
hosts  often  have  ulcer  symptoms  for  more  than  5  years, 
but  refuse  surgical  relief  until  stenoses  or  perforation 
occur.  Examination  of  fresh  tissue  obtained  at  laparotomy 
reveals  numerous  areas  of  malignancy,  frequently  with 
extensive  perigastric  lymph-gland  invasion  or  secondaries 
in  adjacent  or  distant  organs.  Colloid  cancers  appear 
to  spread  rapidly  because  they  are  very  rich  in  epithelial 
elements.  That  the  age  of  the  individual  is  a  factor  of 
relative  value  in  the  determination  of  rate  of  growth  of 
gastric  cancer  seems  to  be  well  supported  by  clinical 
observation.  We  have  observed  18  instances  of  the 
disease  in  patients  below  age  31.  The  average  duration  of 
life  of  12  of  these,  after  sj^mptoms  had  appeared,  was  less 
than  9  months.  Of  our  gastric  carcinomata  over  age  50, 
the  average  length  of  life  after  the  beginning  of  the  com- 
plaint was  rather  longer  than  1)4  J^ears.  In  experi- 
mental animals  where  tumors  have  been  transplanted  a 
similar  factor  influencing  ''takes"  and  growth  rate  has 
been  emphasized  by  Bashford. 

The  state  of  body  nutrition  appears  to  have  an  influence 
upon  the  rate  of  progress  of  gastric  cancer.  It  has  been 
our  experience  that  such  neoplasm  developing  in  well- 
fed,  robust  patients  of  the  erythremic  type  advanced 
rapidly  not  only  locally,  but  also  by  metastasis.     Lean, 


MOKBID   ANATOMY  97 

spare,  sallow  folk  appear  to  tolerate  gastric  cancer  rela- 
tively well.  Tumors  grafted  experimentally  upon  under- 
fed hosts  would  seem  to  grow  more  slowly  than  when 
hosts  were  supplied  with  an  abundance  of  food.  Such 
observations  have  been  made  by  Moreschi  and  by  Rous 
for  mice  and  rats. 

The  location  of  gastric  cancer  in  the  wall  of  the  viscus 
only  relatively  influences  growth  rate.  At  the  orifices 
where  traumata  are  possible  during  chymification  and 
passage  of  food,  neoplasms  in  general  grow  very  rapidly. 
At  such  points  (especially  in  the  pyloric  third  of  the 
stomach)  peristaltic  movements  are  frequent  and  vigorous 
and  digestive  secretions  have  their  highest  potency. 
However,  variation  in  epithelial  cell  content  of  the  tumor 
mass  would  seem  to  be  a  not  negligible  factor  in  the  rate 
of  the  development  of  the  disease  even  at  these  points. 

Location  of  Gastric  Neoplasms. — It  is  a  waste  of  time 
to  speculate  upon  the  location  of  gastric  cancers  unless 
one  is  doing  so  for  the  purpose  of  determining  the  correct- 
ness of  clinical  signs  or  of  symptoms  in  cases  upon  which 
laparotomy  or  necropsy  is  to  be  subsequently  performed. 
That  those  most  proficient  in  the  diagnostic  art  not  un- 
commonly fail  in  attempts  at  localization  of  the  neo- 
plasm can  be  demonstrated  by  a  sojourn  at  any  busy 
surgical  clinic  or  in  a  modern  morgue.  Not  rarely  cases 
clinically  diagnosed  gastric  cancer  prove  to  be  primary 
affections  of  adjacent  viscera.  Consequently,  the  only 
tables  of  worth  regarding  the  situation  of  gastric  carci- 
nomata  are  those  determined  from  post-mortem  exami- 
nations or  at  laparotomy,  and  those  where  the  growths 
have  been  grossly  and  microscopically  proven  to  be  cancer. 
From  dead-house  material  it  is  impossible  to  say  at  what 
part  of  the  gastric  wall  cancer  began.  One  can  only 
note  what  portions   of  the  stomach  are  then  involved. 


98  CANCER    OF   THE    STOMACH 

Such  figures  are  of  but  relative  value.  That  they  do  not 
correspond  with  location  of  neoplasms  removed  at  lapar- 
otomy is  seen  by  comparing  groups  of  collected  statistics. 
The  statistics  for  situation  of  gastric  cancer  commonly 
quoted  in  literature  (even  recent)  follow. 

In  1859  W.  Brinton  analyzed  360  clinical  cases  and 
necropsies.  He  stated  that  in  these  the  pjdorus  was  in- 
volved in  60  per  cent,  and  the  cardia  in  10  per  cent.  In 
1871  Luton  summarized  the  cases  of  Lebert,  Dittrich  and 
Louis.  His  study  comprised  102  instances  of  the  disease. 
The  situations  were  given  thus:  pylorus  57.8  per  cent.; 
lesser  curvature  16.6  per  cent.;  cardia  7.8  per  cent.; 
anterior  or  posterior  wall  4.8  per  cent.;  greater  curvature 
1.9  per  cent.;  general  0.9  per  cent,  and  in  various  parts 
6.8  per  cent.  Welch  later  collected  1,300  cases  of  gastric 
cancer  mainly  from  the  continental  literature.  His  tabula- 
tion is  compiled  largely  from  necropsy  reports.  He  states 
that  in  60.8  per  cent,  the  pylorus  was  involved;  in  11.3 
per  cent,  the  lesser  curvature;  in  8  per  cent,  the  cardia;  in 
5.2  per  cent,  the  posterior  wall;  in  4.6  per  cent,  the  whole 
or  greater  part  of  the  stomach;  in  2.6  per  cent,  the  greater 
curvature;  in  2.3  per  cent,  the  anterior  wall  and  in  1.4 
per  cent,  the  fundus.  In  3.4  per  cent,  there  were  multiple 
tumors.  In  1903  the  Fenwicks  analyzed  263  of  their 
own  cases.  They  state  that  the  pylorus  was  involved  in 
65.3  per  cent.  These  investigators  also  submit  an  analysis 
of  1,850  instances  of  the  disease  collected  from  necropsies 
(?)  in  various  countries.  Of  these,  the  pylorus  was  af- 
fected in  58  per  cent.;  the  lesser  curvature  in  11.5  per  cent.; 
the  cardia  in  9.8  per  cent.;  the  posterior  wall  in  5  per 
cent.;  the  greater  curvature  in  2.8  per  cent.;  the  anterior 
wall  in  2.2  per  cent.;  the  fundus  in  1.5  per  cent.;  general 
involvement  in  6  per  cent.  In  2.9  per  cent,  there  were 
multiple  growths. 


MORBID   ANATOMY 


99 


The  above  summaries  demonstrate  that  necropsy  reports 
exhibit  relatively  sUght  variations  in  the  parts  of  the 
stomach  involved  by  neoplasms  that  have,  in  the  main, 
caused  death  of  those  affected. 

In  our  series  of  921  gastric  cancers,  operatively  and 
pathologically  proved  (but  an  occasional  case  was  studied 
at  necropsy),  there  were  854  instances  where  accurate 
locaHzation  of  the  disease  could  be  determined  or  was 
recorded.     The  summary  is  shown  in  Table  13. 

Table  13 


o 

s^ 

"3 

o 

1 

Situation 

3 
u 

o 

o 

Pi 

o 
a 
•-3 

O 

o 

•c 
S 

c 
< 

§ 
■a 
a 

is-s 

No.  of  cases 

359   201 

102 

79 

30 

20 

20      8  •  26 

Percentages 

42    24.7 

12 

9.3 

3.0 

2.3 

2.30.9    2.9 

Analysis  of  Author's  854  Cases  of  Carcinoma  of  the  Stomach  Showing 
the  Frequency  of  the  Neoplasm  in  Various  Parts  of  the  Viscus. 

These  figures  are  to  be  contrasted  with  those  derived 
from  study  of  post-mortem  or  unproved  cUnical  material. 
The  following  table  demonstrates  that  the  situation  of 
gastric  cancer  as  shown  at  laparotomy  corresponds  rather 
strikingly  to  the  location  of  chronic,  calloused  gastric 
ulcer. 

Table  14 

Number  of  eases         Per  cent. 


Pyloric 

Prepyloric 

Lesser  curvature . 

Near  cardia 

Posterior  wall . .  . 
Anterior  wall. .  .  . 


Total. 


65 

46.4 

5 

3.5 

43 

30.7 

9 

6.4 

12 

8.5 

2 

1.4 

136 

Showing  Location  of  Benign,  Non-retention  Gastric  Ulcers  (Author) 


100  CANCER   OF   THE    STOMACH 

Welch's  figures  for  location  of  gastric  ulcer  also  closely 
approximate  those  of  the  author  for  benign  ulcer  and  for 
gastric  cancer  as  here  given. 

COMPLICATIONS  OF  GASTRIC  CANCER  (General) 

In  our  series  many  of  the  text-book  complications  of 
carcinoma  of  the  stomach  are  missing,  because  a  large 
number  of  instances  were  operated  upon  early.  As  a 
consequence  numerous  terminal  compUcations  of  the  dis- 
ease were  lacking. 

A.  Pyloric  Obstruction. — ^This  occurred  in  some  grade 
in  nearly  72  per  cent,  of  instances.  T\Tien  it  is  recalled 
that  fully  3  out  of  5  of  all  ulcers  and  cancers  are 
located  in  the  pyloric  third  of  the  stomach,  it  is  quite  easy 
to  realize  the  reason  for  this  frequency  of  stenosis.  T\Tien 
the  pyloric  obstruction  was  caused  by  ulcer  in  whose  edge 
was  demonstrated  malignant  tissue  microscopically,  or 
when  the  gastric  affection  was  ulcus  carcinomatosum, 
marked  dilatation  of  the  stomach  was  an  apparently  early 
manifestation  of  this  obstruction.  Where  the  pylorus  was 
intruded  upon  by  a  nodular  growth,  dilatation  of  the 
stomach  was  rarely  so  marked  as  in  the  case  of  ulcer. 
The  average  amount  of  gastric  extract  removed  from  the 
fasting  stomach  of  instances  of  pyloric  obstruction  due 
to  malignant  ulcer  was  350  cc.  The  average  amount 
from  cases  where  a  large  tumor  occluded  the  pyloric 
channel  was  200  cc.  Of  course  there  were  great  variations 
from  the  figures  in  both  illustrations. 

Pyloric  obstruction  is  recognized  readily  by  persistent 
vomiting  of  retained  food,  of  copious  vomitus  and  can 
usually  be  demonstrated  at  the  Roentgen  examination. 

B.  Obstruction  at  Cardia. — This  occurred  in  17  instances 
or  (1.8).     It  usually  resulted  from  malignant  ulcer  at  or 


MOKBID   ANATOMY  101 

near  the  cardia,  tumor  situated  at  the  fundus  or  high  on  the 
lesser  curvature  or  from  the  pressure  of  gland  metastases 
about  the  cardia.  It  is  recognized  clinically  by  dysphagia, 
vomiting  soon  after  food  ingestion,  rapid  emaciation, 
scanty  urine,  obstruction  to  the  passage  of  a  stomach  tube 
with  or  without  free  bleeding  and  by  a;-ray  examination. 

C.  Malignant  Hour-glass. — This  is  a  frequent  com- 
plication in  instances  where  a  '^saddle  ulcer"  has  become 
malignant  or  where  large  tumor  masses  project  into  the 
gastric  lumen.  While  it  may  be  suspected  from  the  clinical 
history,  the  vomiting  soon  after  eating,  the  nature  of  the 
abdominal  tumor,  the  appearance  of  the  stomach  upon  in- 
flation with  air  and  the  auscultation  of  the  abdomen,  it  is 
most  conclusively  demonstrated  at  the  Roentgen  examina- 
tion. In  our  cases  malignant  hour-glass  occurred  in  some 
degree,  approximately  in  1  out  of  15  cases. 

D.  Hemorrhage  is  a  sign  in  from  15  to  25  per  cent,  of 
all  cases.  Hemorrhage  occurred  in  more  than  19  per  cent, 
of  our  cases  irrespective  of  the  type  of  the  lesion.  In  the 
instance  where  malignancy  has  supervened  upon  a  previous 
gastric  affection,  usually  of  the  type  clinically  classed  as 
peptic  ulcer,  hemorrhage  may  be  copious  and  associated 
with  symptoms  of  shock.  When  malignancy  has  become 
well  established,  sudden,  severe,  copious  hemorrhages  are 
not  the  rule.  There  is  in  the  large  majority  of  instances, 
however,  constant  seepage.  This  may  be  recognized  by 
chemical  tests  for  altered  blood  in  the  gastric  extracts  and 
the  feces.  Such  tests  were  positive  in  nearly  9  out  of 
10  of  our  cases  of  gastric  cancer. 

E.  Perforation. — In  advanced  cancer  of  the  stomach 
perforation  occurs  in  from  2.5  per  cent,  to  6  percent,  of  all 
instances.  It  may  be  sudden  or  gradual.  Sudden  per- 
foration is  as  a  rule  readily  recognized,  if  there  is  a  history 


102  CANCER  OF  THE  STOMACH 

of  a  malignant  gastric  affection  rather  chrome.  This  is 
associated  with  epigastric  tumor  in  more  than  3  out 
of  4  instances.  Pain  has  generally  been  not  so  severe  as 
to  be  classed  as  ''colicky."  After  vomiting,  a  fall,  a  heavy 
meal  or  some  sudden  exertion,  sudden  sharp  lancinating 
abdominal  pain  may  come  on.  This  is  associated  with 
shock,  subnormal  temperature,  abdominal  distention  and 
great  prostration.  Temperature  generally  rises  fairly 
rapidly  and  terminal  evidences  of  septic  peritonitis  be- 
come apparent. 

Gradual  perforation  of  a  cancer  of  the  stomach  sometimes 
occurs.  There  may  be  some  attacks  of  colicky  pain  but  the 
leakage  from  the  stomach  is  so  slight  that  opportunity  for 
walling  it  off  occurs.  As  a  consequence,  perigastric  abscess 
or  localized  abdominal  abscess  between  the  stomach  and 
other  viscera  develop.  The  following  case  illustrates 
these  features: 

Perforating  Gastric  Cancer;  Perigastric  Abscess;  Few  symp- 
toms: 
Mrs.  L.  N. — Age  54,  Swedish,  housekeeper. 

Family  History. — Mother  died  from  carcinoma  mammcs. 

Personal  History. — Always  well  and  strong  to  about  1 
year  ago ;  then  began  to  lose  weight  gradually,  but  without 
symptoms.  Two  months  since  unaccountable  anorexia 
developed.  One  month  ago  began  to  belch  much  gas 
following  food  intake.  Two  weeks  since,  had  a  sudden 
sharp  pain  in  the  left  loin.  It  came  on  at  night  and  dis- 
tress lasted  3  days.  It  then  practically  disappeared.  A 
few  days  ago  noted  a  tender  swelling  along  the  left  rib  edge. 
This  increased  in  size  and  gradually  advanced  across  the 
epigastrium  to  the  mid-line.  It  became  much  larger  and 
very  tender.  Thinks  she  had  fever;  had  chilly  sensations 
daily  and  sweated  rather  freely. 

Appetite. — Capricious.     Never  vomited. 

Bowels. — Costive. 

Urine. — Negative. 


MORBID   ANATOMY  103 

Weight.- — One  year  ago,  180;  three  months  ago,  170; 
present,  154. 

Examination. — Temp.,  101;  pulse,  100;resp.,  24.  Cheer- 
ful, comfortable  appearing  woman;  mucosae  pale,  but  cheeks 
pink. 

Throat  and  Neck. — Negative. 

Thorax. — Heart  sounds  weak;  lungs,  negative. 

Traube's    Space. — Dull  on  percussion. 

Splenic  dulness  at  eighth  rib  in  axilla. 

Abdomen. — Tense  swelling  from  left  rib  edge  across  lower 
epigastrium  to  right  of  navel.     Fluctuation  (?) 

Rectum. — Negative. 

Blood.~Rg.,  70  per  cent. ;  r.b.c,  3,880,000;  w.b.c,  16,000. 

Operation. — Incision  over  most  prominent  part  of  epi- 
gastric tumor.     A  quantity  of  creamy,   thick  fluid  came 
out  under  tension.     Drainage. 
Subsequent  Course: 

Abdominal  Examination. — After  abscess  had  been  drained 
revealed  a  firm,  fixed  mass  occupying  the  entire  left  epigas- 
trium. 

Test-meal. — Marked  12-hour  retention.  Total  acidity, 
50;  free  Hcl,  0;  lactic  acid-f;  altered  blood+;  Wolff 4-, 
microscopic  examination  revealed  large  numbers  of  bacilli 
of  the  Oppler-Boas  type. 

X-ray. — Entire  pylorus,  pars  media  and  greater  curva- 
ture involved  with  a  fungoid  growth.  Almost  complete 
pyloric  obstruction. 


F.  Fistulas  usually  result  from  perforation  with  a 
resultant  abscess  cavity  or  direct  connection  between  the 
stomach  or  the  large  bowel  or  develop  from  necrosis  of  a 
contiguously  extending  tumor.  Gastrocolic  fistulse  occurs 
in  from  1  to  4  per  cent,  of  late  cases  of  gastric  cancer. 
Clinically  they  are  recognized  by  a  previous  malignant 
gastric  disease  later  showing  evidences  of  fsecal  contents 
in  the  vomitus,  in  diarrhea  of  the  lienteric  type,  hemorrhage, 
the  speedy  appearance  of  a  test  capsule  of  carmine  in  the 
stool  or  by  the  Roentgen  ray. 


104  CANCER   OF   THE    STOMACH 

Gastric  Cancer,  Involving  Transverse  Colon,  Pancreas  and 
Liver;  Hemorrhage;  Metastases  to  Pelvis;  Anemia;  Few 
Clinical  Symptoms: 
Mr.  L.  J. — Age  57,  Swedish,  cabinet  maker. 

Family  History. — Mother  died  of  cancer  (pelvic).  Father 
and  sister  died  of  pulmonary  tuberculosis. 

Personal  History. — Malaria  many  years  ago.  Denies 
venereal. 

Present  Trouble. — Nearly  2  years  ago  began  to  have  at- 
tacks of  diarrhoea.  These  came  on  at  intervals  of  from 
2  weeks  to  3  months.  Occasionally  passed  bright  red 
blood  in  stool.  Three  months  ago  fainted  away  while  at 
work,  and  was  taken  to  a  hospital.  Since  then  has  gradu- 
ally become  weaker  and  has  lost  weight. 

Appetite.— Gradual  failure. 

Bowels.- — Occasional  diarrhceic  stool. 

Weight. — One  year  ago  170  pounds;  present,  117. 

Examination. — Tired  looking,  pale,  emaciated  blonde. 

Mouth. — Teeth  poor;  tongue  coated. 

Neck. — Enlarged  left  supraclavicular  glands. 

Thorax. — Heart,  weak  muscle  sounds. 

Abdomen. — Irregular  mass  in  high  and  middle  thorax, 
moving  on  respiration,  tender.  Small  amount  free  fluid 
in  peritoneal  sac. 

Rectal. — Several  nodules  in  Douglas  pouch.     Bleeding 
hemorrhoids. 
Laboratory  Examinations: 

Blood.— Kg.,  40  per  cent.;  r.b.c,  3,490,000;  w.b.c,  5,100. 

Wassermann  and  Luetin  Tests. — Negative. 

Test-meal. — Twelve-hour  retention.  Total  acidity,  20; 
free  Hcl,  0;  lactic  acid+;  altered  blood-H;  Oppler-Boas 
bacilli. 

X-ray  Examination. — Filling  defect  involving  pyloric 
half  of  stomach,  and  invading  the  transverse  colon,  pancreas 
and  liver  (?). 

Laparotomy . — High  median  incision.  Mass  involving 
pyloric  half  of  stomach  and  extending  along  coronary 
artery  to  esophagus.  Transverse  colon,  omentum  and 
head  of  pancreas  also  involved.     Few  nodules  in  liver. 

Operation. — Explored. 

Pathologic  Report. — (Post-mortem)  Adenocarcinoma. 


MORBID    ANATOMY  105 

G.  Metastases  occur  most  commonly  to  the  lymphatics 
in  gastric  cancer.  T\'e  have  tabulated  their  significance  in 
Chapter  IV.  In  more  than  70  per  cent,  of  our  cases  of 
gastric  cancer,  metastases  to  the  perigastric  lymph  chains 
were  demonstrated.  As  has  been  pointed  out  by  ^NlacCarty 
and  Blackford,  the  extent  of  perigastric  lymph-gland  in- 
vasion bears  no  relation  to  the  size  of  the  primary  process 
in  the  stomach  wall;  the  gross  size  of  the  individual  lymph 
nodes  is  no  definite  evidence  as  to  whether  or  no  they 
contain  mahgnant  tissue;  mahgnant  glands  are  usually 
hard  upon  palpation  and  thek  cut  surface  has  a  glistening 
white  color.  Upon  the  degree  of  lymph-gland  invasion 
depends  absolutely  the  prognosis  in  a  given  case,  whoU}- 
irrespective  of  the  size  of  the  primary  growth. 

Metastases  to  the  liver  occur  in  from  15  to  35  per  cent,  of 
all  instances  of  late  gastric  cancer.  In  our  series  (which 
comprises  many  cases  where  the  diagnosis  of  malignant 
disease  of  the  stomach  was  made  microscopicaUy)  the 
liA-er  was  involved  in  18  per  cent,  of  cases.  AYith  the  in- 
volvement of  the  liver  one  not  infrequently  notices  the 
development  of  ascites.  This  is  due  to  interference  with 
the  portal  cumulation  and  also  to  direct  involvement  of  the 
peritoneum.  The  ascites  usually  develops  very  gradually, 
but  there  are  cases  where  a  rapid  accumulation  of  ascitic 
fiuid  occurs.  In  such  instances  a  fatal  termination  super- 
venes in  a  short  time. 

Metastases  to  the  Lungs. — If  the  disease  is  allowed  to 
progress  without  interference,  metastatic  involvement  of 
the  pleura,  pericardium,  the  lung  tissue  and  the  mediastinal 
lymphatics  is  noted  in  from  5  to  11  per  cent,  of  aU  instances. 
If  the  pleura  is  involved  serous  exudation  may  appear  rapidly. 
The  puncture  fluid  not  infrequently  shows  blood  cells, 
cells  with  at^-pical  mitotic  forms  and  an  increase  in  the 


106  CANCER  OF  THE  STOMACH 

incoagulable  nitrogen  (Roger  Morris).  If  lung  tissue  is 
actually  invaded,  malignant  consolidation  or  necrosis  with 
abscess  result, 

H.  Jaundice  may  result  from  direct  extension  of  the 
gastric  growth  to  the  liver  or  the  gall  tract,  from  pressure 
of  a  pyloric  tumor  upon  the  bile  passages,  from  malignant 
invasion  at  the  head  of  the  pancreas  and  consequent  obstruc- 
tion of  the  common  bile  duct  or  from  pressure  upon  the 
biliary  passages  by  malignant  lymph  nodes.  In  early  cases 
of  gastric  cancer,  jaundice  is  present  in  about  3  per  cent,  of 
instances.  Where  the  growths  are  extensive,  jaundice 
occurs  in  12  to  15  per  cent,  of  cases. 

I.  Thrombosis  is  a  terminal  complication  of  gastric 
cancer.  It  is  relatively  infrequent.  It  may  be  arterial 
or  venous.  The  vessels  most  commonly  involved  are  the 
femoral,  saphenous,  the  external  iliacs,  the  subclavian  or 
the  brachial.  If  the  patients  are  not  too  far  gone,  throm- 
bosis is  evidenced  by  local  pain,  edema  or  discolora- 
tion of  tissues. 

J.  Enteritis  occurs  concomitantly  with  the  majority 
of  gastric  cancers.  It  varies  greatly  in  degree  or  extent. 
Not  rarely  tenderness  over  the  bowels,  colicky  abdominal 
pains,  diarrheic  stools  or  the  appearance  of  hemorrhoids 
indicate  deficient  function  on  the  part  of  the  small  or  large 
bowel. 

K.  Nephritis. — It  is  difficult  to  estimate  whether  anoma- 
lies on  the  part  of  the  kidneys  are  due  to  the  disease  or 
are  malfunctions  to  be  expected  in  individuals  past  middle 
life.  In  our  series  albumin  was  noted  in  17  instances  and 
casts  in  19. 

L.  Nervous  complications  are  comparatively  rare  oc- 
currences in  gastric  cancer.  A  certain  melancholy  frame 
of  mind  not  unnaturally  develops  in  individuals  who  real- 


MORBID    ANATOMY  107 

ize  that  they  are  fatally  ill  with  a  disease  around  which 

clings   much   popular   dread.     Fenwick   claims   that   this 

may  amount  to  insanity  in  1.6  per  cent,  of  instances.     We 

have  no  case  of  insanity  as  a  complication  in  our  series. 

Neuritis,  paralyses  or  sometimes  general  tonic  spasms  of 

the  tetanoid  type  have  been  described  associated  with  this 

disease.     Whether  such  complications  are  directly  caused 

by  the  neoplasm  or  are  evidences  of  functional  or  toxic 

disturbances  apart  from  the  gastric  cancer,  it  is  difficult 

to  state. 

ADDENDUM 

A  RAPID  METHOD    OF    CUTTING   AND    STAINING 
SECTIONS  OF  TISSUE  (WILSON) 

Place  a  piece  of  tissue  no  thicker  than  3  mm.  on  freez- 
ing stand  and  add  enough  dextrin  solution  of  the  consist- 
ency of  molasses  to  cover.  Then  turn  nozzle  allowing  the 
CO2  to  escape  until  the  tissue  is  just  hard  enough  so  that 
sections  may  be  cut  without  crumbling.  Under  proper 
conditions  such  as  a  sharp  knife,  proper  density  of  tissue, 
proper  temperature,  etc.,  sections  may  be  cut  as  thin  as  5 
microns.  Keep  the  knife  continually  flooded  with  water 
while  cutting  the  sections.  Use  ball  of  the  finger  to  remove 
section  from  the  knife  and  place  section  in  a  dish  of  water. 
Pieces  of  tissue  that  have  been  hardened  for  12  to  24 
hours  in  10  per  cent,  formalin  can  be  cut  with  much 
greater  ease  than  when  not  so  treated.  The  sections  so 
made  may  be  stained  either  by  the  hematoxylin-eosin 
method  and  permanently  mounted  or  stained  by  the 
following  method  which  is  much  more  rapid  but  less 
permanent. 

Rapid  Method  of  Staining. — Place  the  section  in  a 
small  dish  containing  about  a  dram  of  Brun's  polychrome 
methylene-blue  (Grubler's)  solution  for  10  to  15  seconds 


108  CANCER    OF   THE    STOMACH 

and  transfer  immediately  to  water.  After  rinsing  a  few 
seconds,  place  in  Brun's  glucose  medium  to  clear  the 
sections. 

Formula  for  Brun's  Glucose  Medium.  —  (a)  Glucose, 
240  cc.     Hot  distilled  water,  840  cc.     Mix  thoroughly. 

(6)  Spirits  of  camphor,  60  cc.  Glycerine,  60  cc.  Mix 
thoroughly. 

Mix  (a)  and  (6)  together  and  filter. 

After  section  has  been  in  above  solution  a  few  seconds 
it  is  floated  upon  a  microscopic  slide,  the  excess  fluid  al- 
lowed to  drip  off  and  a  cover  slip  placed  in  position.  It 
is  ready  for  examination.  Under  ordinary  conditions  the 
slide  will  keep  2  to  3  weeks.  By  this  method  one  may  have 
a  well-stained  section  of  tissue  ready  for  microscopical 
examination  within  3  minutes.  Either  the  Spencer  or 
Leitz  freezing  microtomes  are  suitable  for  this  work. 
Either  may  also  be  used  for  the  cutting  of  celloidin  or 
paraflSn  blocks. 

REFERENCES 

ViRCHOw:  "Pathologie  des  Tumeurs,"  vol.  vii,  p.  236. 

Fenwick,  S.:  "Cancer  and  Other  Tumors  of  the  Stomach,"  Phila- 
delphia, 1903. 

Yates:  Annals  of  Surgery,  1006,  Oct.,  p.  599. 

Clendenning:  Am.  Jour.  Med.  So.,  1909,  Aug.,  p.  1. 

Frazier:  Am.  Jour.  Med.  Sc,  1914,  June,  p.  781. 

Campbell:  Surg.  Gyn.  and  Obstets.,  1915,  Jan.,  p.  66. 

Waldeyer:  "  Arbeiten  uber  den  Krebs,"  Virchow's  Archiv.,  41,  p.  470. 

Rokitansky:  Lehrbuch  der  pathol.  Anatomie,  3  Aufl.,  iii,  p.  171. 

Rous:  Jour.  Exp.  Med.,  1910,  vol.  xii.  No.  5;  and  Proc.  Am.  Philo- 
sophical Soc,  1912,  vol.  li.  No.  205. 

Rous  AND  Jones:  Jour.  Exp.  Med.,  1914,  vol.  xx,  No.  4. 

Rous,  Murphy  and  Tytler:  Jour.  Am.  Med.  Assn.,  1912,  June  8, 
p.  1751. 

Murphy:  Jour.  Exp.  Med.,  1913,  vol.  xvii. 

Levin:  Jour.  Exp.  Med.,  1912,  No.  12,  p.  149. 

Snow:  Journ.  of  Infect.  Dis.,  vol.  iv,  No.  3,  p.  385. 

Smith:  Bulletins  Nos.  213  and  255,  U.  S.  Dept.  of  Agriculture,  1912. 


MORBID    ANATOMY  109 

Fibigeb:  Berl.  Klin.  Wchnschr.,  1913,  Feb.  17,  p.  289. 

MacCartt,  W.  C,  and  Wilson:  Am.  Jour.  Med.Sc,  1909,  Dec,  p.  846. 

MacCarty,  W.  C:  Surg.  Gyn.  and  Obstets.,  1910,  x,  p.  449. 

MacCartt  and  Broders:  Arch,  of  Int.  Med.,  1914,  xiii,  p.  208. 

MacCarty,  W.  C:  Jour,  of  Iowa  State  Med.  Soc,  1914,  iv,  p.  1. 

MacCarty,  W.  C:  Am.  Jour.  Med.  Sc,  1915,  No.  4,  p.  469. 

Rous  and  Murphy:  Jour.  Exp.  Med.,  1914,  vol.  xx,  No.  4. 

Gay:  Jour.  Med.  Research,  1909,  Feb.,  p.  175. 

Carrel:  Jour.  Exp.  Med.,  1912,  vol.  xvi,  No.  2. 

MoRESHi:  Ztschrft.  f.  Immunitatsforch,  1909,  vi,  p.  651. 

Rous:  Proceedings    of    the    Society   for    Experimental   Biology    and 

Medicine,  1911,  viii,  p.  128;  and  Jour.  Exp.  Med.,  1914,  vol.  xx, 

No.  5. 
Brinton:  "Diseases  of  the  Stomach,"  1859. 
Luton:  "Magenkrebs,"  Nouveau  diction  de  Med.,  Paris,  1871. 
Welch:  "Cancer  of  the  Stomach,"  Am.  Syst.  of  Med.,  ii. 
Fenwick,  S.:  {Loc  cit.) 

MacCarty  and  Blackford:  Annals  of  Surg.,  1912,  June,  p.  811. 
Morris,  Eoger:  Arch,  of  Int.  Med.,  1911,  Oct.,  p.  457. 
Wilson:  Jour.  Am.  Med.  Assn.,  1905,  Dec.  2. 


CHAPTER  III 
SYMPTOMATOLOGY 

The  work  of  the  surgeon  and  of  the  cellular  pathologist 
has  demonstrated  that  the  cases  of  gastric  cancer  which 
are  cured,  or  given  any  considerable  lease  of  life,  are  those 
where  such  early  diagnosis  of  malignancy  has  been  made  as 
to  permit  of  the  resection  of  the  neoplasm  while  it  is  still 
a  locahzed  process. 

The  pathologist,  familiar  with  fresh  tissue  examination, 
has  proved  that  the  highest  proportion  of  operatively  cured 
cases  of  gastric  cancer  makes  up  that  group  where  the 
early  diagnosis  consisted  in  the  recognition  of  malignancy 
(with  the  highest  power  microscope)  in  extirpated  sections 
of  the  gastric  wall  in  patients  where  the  disease  seemed 
chnically,  surgically  and  macroscopically  chronic,  calloused 
gastric  ulcer. 

The  early  diagnosis  of  malignancy  in  these  curable 
cancer  cases  involved  the  histologic  demonstration  of 
intracellular  progressive  nuclear  hypertrophy,  undiffer- 
entiated (functionally)  gland-cells,  exuberant  hyperplasia 
of  gland  structures  and  beginning  invasion  of  hyperplastic 
epithelial  cells  into  non-epithelial  portions  of  the  stomach 
wall. 

The  cases  deriving  the  greatest  benefit  from  operation 
are  those  in  which  the  fewest  areas  of  malignant  epithelial 
hyperplasia  are  found,  or  those  where  active  gland-cell 
hyperplasia  exists,  which  permit  of  a  presumptive  histologic 
diagnosis  of  malignancy. 

110 


SYMPTOMATOLOGY  111 

Specimens  of  extirpated  tissue  microscopically  revealing 
the  least  advanced  epithelial  cellular  faults  are  generally, 
but  not  always,  associated  with  the  minimum  of  peri- 
gastric lymph-gland  malignancy. 

In  gastric  cancer,  the  extent  of  lymph-gland  metastasis 
controls  most  certainly  the  prognosis.  The  size  of  the 
local  neoplasm,  in  the  stomach  wall,  is  but  a  relative  index 
of  the  possible  extent  of  perigastric  lymph-gland  in- 
vasion. The  size  of  gastric  lymph  glands,  themselves,  is 
no  criterion  of  the  degree  to  which  they  may  be  malig- 
nantly invaded.  Minute  glands  may  contain  a  greater 
number  and  more  perniciously  active  cancer  cells  than  do 
large  glands.  Hence,  the  diagnosis  (and  the  prognosis) 
of  the  stage  of  a  gastric  cancer  is  primarily  in  the  hands  of 
the  surgical  pathologist. 

From  the  foregoing  facts  it  would  appear  that  the  past 
decade  has  contributed  the  most  radical  clinical  information 
regarding  gastric  cancer  that  has  come  to  us  since  its 
classic  description  by  Virchow  and  Waldeyer.  It  would 
seem  that  a  great  prophylactic  advance  were  now  possible. 
Previously,  the  clinician's  complaint  has  been  that  the 
gastric  cancer  case  came  to  him  for  aid  only  when  the 
disease  was  so  far  advanced  that  the  diagnosis  and  prognosis 
stood  revealed  on  the  face  of  the  patient.  One  could  run 
and  read.  Early  diagnosis  mainly  implied  detecting 
gastric  malignancy  before  general  carcinosis  and  early 
death  threatened.  Medical  treatment  but  prolonged 
misery.  The  surgeons  who  operated  on  these  patients 
offered  little.  But  they  were  a  bold  lot:  scientific  vikings, 
who,  by  persistent  exploration,  have  come  back  to  the  less 
venturesome  members  of  their  clan  with  an  epoch-making 
discovery.  We  can  now  state  that  the  early  diagnosis 
of  gastric  cancer  is  a  microscopic  one;  it  is  possible  from 


112  CANCER  OF  THE  STOMACH 

histologic  study  of  freshly  removed  tissue;  such  tissue  is  seen 
least  developed  in  those  patients  whose  gastric  history  has 
been  that  of  chronic,  recurring  peptic  ulcer  and  in  whom  to 
eye  and  hand  such  ulcer  appears  at  laparotomy. 

As  is  to  be  expected,  this  view  of  the  situation  is  not 
as  yet  generally  accepted.  Healthy  skepticism  is  a  scien- 
tific virtue,  but  doubt,  unsupported  by  facts,  is  a  pernicious 
habit.  This  sluggishness  of  the  professional  mind  might 
be  discouraging  to  both  investigators  and  trusting  patients, 
had  it  not  been  shown  that  gastro-enterologic  history 
is  rich  in  similar  examples.  It  is  but  a  few  years 
since  ' '  catarrhal  gastritis, "  "  hyperacidity, "  ' '  Reichmann's 
disease"  and  "pyloric  spasm"  were  considered  definite 
disease  entities.  Only  recently,  and  reluctantly,  has 
the  world  medical  accepted  these  pet  ailments  for  their 
face  value,  as  being  symptoms  of  gastric  malfunction 
associated  with  peptic  ulcer  or  subinfections  of  the  ap- 
pendix or  gall-bladder. 

This  introduction  is  necessary  to  support  the  grouping 
of  symptom-complexes  of  gastric  cancer  which  the  study  of 
the  921  instances  comprising  our  series  seems  to  establish. 

Our  material  can  be  grouped  under  the  following  symp- 
tom-complex heads : 

I.  Gastric  cancer  in  individuals  who  came  to  laparotomy 
for  clinically  benign  gastric  ulcer,  and  in  whom  cancer  was 
diagnosed  microscopically. 

II.  Gastric  cancer  clinically  developing  in  patients  with 
years  of  antecedent  dyspepsia  of  the  "peptic  ulcer  type," 
in  whom  malignancy  subsequently  appeared. 

III.  Gastric  cancer  in  individuals  who  prior  to  the  onset 
of  a  malignant  disease  had  enjoyed  perfect  gastric  health. 

IV.  Gastric  cancer  in  individuals  in  whom  malignancy 
followed  periods  of  gastric  disturbance  of  no  clinical  type. 


SYMPTOMATOLOGY  113 

V.  Gastric  cancer  in  individuals  who  presented  few  clinical 
evidences  of  a  malignant  process  primary  in  the  stomach  wall. 

VI.  Gastric  cancer  secondary  to  an  extragastric  malignant 
process. 

Group  I.  Gastric  Cancer  in  Patients  Who  Came  to  Laparotomy  for 

Clinically  Benign  Gastric  Ulcer  and  in  Whom  Cancer  was 

Microscopically  Diagnosed 

This  group  comprised  72  cases  (7.8  per  cent.).  There 
were  44  males  and  28  females.  The  average  age  was  56.5 
years.  The  shortest  period  of  gastric  distress  was  3^ 
years,  the  longest  42  years,  the  average  13.7  years.  There 
was  a  family  or  blood  relationship  history  of  malignancy 
in  3  instances  (4.1  per  cent.). 

Mode  of  Onset. — ^The  disease  had  been  periodic,  without 
acute  attacks  in  42  cases  (58.3  per  cent.) .  Between  attacks 
until  complications  ensued  (stenoses,  perforation,  etc.) 
the  patients  generally  enjoyed  good  gastric  health.  The 
periods  of  exacerbation  varied  in  frequency  from  1  every 
week  or  10  days  to  one  in  3  or  4  years.  Peculiar  seasonal 
relationship  of  the  ''spells"  of  dyspepsia  were  noted:  fall 
or  spring  or  both  seemingly  bringing  such  on,  or  aggravating 
an  already  present  dyspepsia. 

In  19  cases  (26  per  cent.)  the  disease  had  been  chronic 
and  continuous.  There  were  frequently  noted  times  when 
the  gastric  malfunction  was  of  increased  severity. 

Eleven  patients  (15.2  per  cent.)  gave  history  of  acute 
attacks  of  dyspepsia,  either  at  infrequent  periods  or  at 
some  phase  of  a  continuous  ailment.  These  acute  attacks 
usually  implied  severe,  often  colicky,  abdominal  pain, 
vomiting,  hemorrhage  with  or  without  symptoms  of  shock, 
loss  of  appetite  or  strength,  constipation,  or  occasionally 
jaundice. 


114  CANCER   OF   THE    STOMACH 

The  Digestive  Disorder. — Anorexia  was  generally  evi- 
denced only  during  the  periods  of  abdominal  discomfort. 
There  was  good  appetite  between  such.  Not  infrequently, 
the  fear  of  bringing  on  pain  by  ingestion  of  food,  normal 
in  amount  and  quality,  the  dread  of  precipitating  hemor- 
rhage, or  oscillations  between  various  types  of  ''diet," 
resulted  in  the  development  of  a  poor  appetite  habit. 
Mild  or  marked  degrees  of  stenosis  at  cardiac  or  pyloric 
orifices  occurred  in  30  instances  (41.1  per  cent.).  In  such 
cases  poor  appetite  resulted  from  pain  on  ingestion,  nausea 
or  fear  of  precipitating  vomiting. 

Dysphagia  was  a  late  symptom  in  3  instances  (4.1  per 
cent.).  It  resulted  from  calloused  ulcer  partly  occluding 
the  cardia  or  from  severe  spasm  at  that  orifice  as  a  conse- 
quence of  an  irritated  ulcer  high  on  the  lesser  curvature 
of  the  stomach. 

Water-brash  with  or  without  pyrosis  often  proved  an 
annoying  symptom.  It  was  a  major  complaint  at  some 
stage  of  the  disease  in  55  cases  (76.4  per  cent.).  In  the 
ulcer  patients  exhibiting  periodicity  of  complaint  water- 
brash  and  pyrosis  were  generally  early  warnings  that  a 
''spell"  was  coming  on.  The  greatest  discomfort  from 
these  sources  occurred  from  1  to  4  hours  following  food  in- 
gestion in  the  majority  of  instances.  In  cases  where  the 
digestive  disturbance  was  continuous,  patients  frequently 
stated  that  they  were  rarely  free  from  "sour  stomach." 
Prompt  rehef  of  these  symptoms  was  commonly  obtained 
by  ingestion  of  food,  the  taking  of  alkahes,  by  vomiting, 
by  gastric  lavage,  or  by  free  catharsis. 

Bowels. — Constipation  was  observed  in  47  cases  (66.9 
per  cent.).  It  was  frequently  periodic  and  heralded  the 
approach  of  a  dyspeptic  storm.  Diarrheic  stools  were 
described  by  6  patients  (8.3  per  cent.). 


SYMPTOMATOLOGY  115 

The  tongue  was  described  as  '' coated"  in  62  instances 

(86  per  cent.)- 

Nutrition. — There  were  16  patients  who  had  lost  no 
weight  and  were  in  excellent  flesh.  Thirty-four  cases  had 
lost  less  than  10  pounds.  In  22  the  weight  loss  ranged 
from  above  10  pounds  to  as  great  as  39  pounds.  Weight 
was  frequently  noted  as  having  been  lost  in  the  attacks  or 
periods  of  exacerbation  of  the  disease.  It  was  commonly 
gained  when  the  dyspeptic  agony  had  passed.  Associated 
even  with  marked  and  rapid  weight  loss,  there  was  but 
rarely  cachexia,  such  as  is  usually  present  in  malignancy. 

Blood. — The  average  hemoglobin  was  80  (Tallqvist  or 
Dare).  The  red-cell  count  averaged  4,200,000.  Leuco- 
cytes were  above  9,000  in  but  2  instances.  These  were 
both  ulcers  in  which  perforation  was  subsequently  dem- 
onstrated. 

Strength  was  "poor"  in  18  patients. 

Vomiting. — This  proved  a  troublesome  symptom  at 
some  phase  of  the  ailment  in  58  cases  (80  per  cent.).  The 
vomitus  was  the  color  of  ingested  food,  white,  green  or 
yellowish.  Food  was  not  infrequently  poorly  chymified. 
Copious  vomitus  of  the  ''delayed"  type  was  a  late  mani- 
festation in  32  instances  (44  per  cent.) .  Blood  was  vomited 
by  24  patients  (34.5  per  cent.).  Emesis  occurred  with 
the  greatest  frequency  from  2  to  4  hours  following  food 
ingestion.  Five  cases  with  cardiac  or  high  lesser  curvature 
ulcers  vomited  shortly  after  the  swallowing  of  food.  The 
vomitus  was  described  as  sour,  bitter,  or  salt. 

Hemorrhage. — Hematemesis  was  experienced  by  24  pa- 
tients (34.5  per  cent.)  and  melena  by  3  (4.2  per  cent.). 
Helena  without  hematemesis  occurred  once. 

The  stool  examined  at  some  phase  of  the  ailment  had 


116  CANCER   OF   THE    STOMACH 

given  chemical  test  for  altered  blood  in  52  cases  (71.1 
per  cent.)  by  the  benzidin  or  guaiac  reactions. 

Pain. — Some  form  of  abdominal  distress  was  complained 
of  by  every  patient  in  this  group  at  some  time  during 
the  disease.  Only  3  instances  were  recorded  where  dis- 
tress was  constantly  below  the  level  of  the  navel.  These 
were  lesser  curvature  or  anterior  wall  ulcers  in  rather  low- 
lying  stomachs. 

There  was  usually  general  epigastric  distress.  In  23 
cases  (31.9  per  cent.)  more  intense  pain  was  a  local  com- 
plaint in  addition  to  its  being  of  widespread  distribution. 
In  18  of  these  instances  the  severe  complaint  was  at  or  to 
the  left  of  the  mid-abdominal  line. 

Type  of  abdominal  distress  varied.  In  10  patients 
(14  per  cent.)  it  was  described  as  '^ colicky,"  "boring," 
"knife-like."  Fifty-four  cases  (73  per  cent.)  complained 
of  "burning,"  "soreness,"  "gnawing."  In  the  remaining 
instances  vague  "full" — "heavy" — "bloated"  or  "pres- 
sure" sensations  were  complained  of. 

The  time  of  occurrence  of  abdominal  distress  bore 
definite  relation  to  food  intake  in  58  cases  (81  per  cent.). 
In^these  patients  pain  came  on  from  2  to  5  hours  after  eat- 
ing and  disappeared,  or  was  lessened  by  again  taking  food. 
Until  complications  ensued  (especially  stenoses)  the  quaUty 
of  food  eaten  seemed  to  have  little  significance  toward  the 
stopping  of  the  distress.  Quantity  frequently  appeared  to 
exert  greater  influence:  longer  relief  was  obtained  after  a 
heavy  meal  than  after  a  small  one,  but  when  pain  re- 
curred it  was  then  generally  of  greater  severity.  Other 
forms  of  pain-relief  were  in  the  order  of  their  usefulness: 
alkalies,  vomiting  or  lavage.  In  about  13  per  cent,  opi- 
ates were  required  at  some  time. 

There  were  5  cases  where  pain  was  relieved  by  none  of 


SYMPTOMATOLOGY  117 

the  routine  remedies.  It  was  continuous,  rarely  very  sharp, 
and  bore  no  relation  to  food  intake.  The  patients  had  not 
been  given  opiates. 

There  were  7  instances  where  pain  was  of  so  violent 
a  character  that  ulcer  perforation  was  suspected.  Hem- 
orrhage was  associated  3  times.  At  laparotomy,  some 
grade  of  perforation  was  made  out  in  5  of  these  cases.  A 
stone  in  the  cystic  duct  was  found  once. 

Test-meal  Findings. — A  complete  discussion  of  this  aspect 
of  this  group  of  gastric  cancers  is  found  in  Chapter  V. 
Briefly:  Twelve-hour  retention  was  demonstrated  in  33 
cases  (46  per  cent.);  total  acidity  averaged  62,  and  free 
hydrochloric  acid  38.  Lactic  acid  was  demonstrated  by 
the  Uffelmann  test  twice.  Blood  by  chemical  test  was 
noted  in  18  gastric  extracts  (25  per  cent.).  Wolff-Jung- 
hans'  test  for  increased  soluble  albumin  was  positive  5 
times  in  9  cases  tested.  Microscopic  examination  of  gastric 
extracts  revealed  no  instance  where  organisms  of  the  Oppler- 
Boas  type  were  seen.  In  84  per  cent,  of  the  stomachs 
showing  gastric  retention,  yeasts  and  sarcinse  were  observed. 

HISTORIES 
Cases  Illustrating  Group  I  Type  of  Gastric  Cancer 

1.  Chronic,  Recurri7ig  Peptic  Ulcer  of  Non-stenosing  Type— 
Excisio7i;  Pathologically  Malignant: 

Mr,  F.  B. — Age  53,  German,  farmer. 

Family  History. — Negative. 

Personal  History. — Denies  venereal;  married;  2  children; 
wife  has  had  no  miscarriages;  measles  at  12;  never  used 
tobacco  or  alcohol;  always  worked  hard. 

Digestive  History. — For  the  past  15  years  has  had  attacks 
of  ''stomach  trouble."  Up  to  6  months  ago  these  came  on 
2  or  3  times  a  year,  being  especially  aggravating  toward  the 
Christmas  holidays.  The  attacks  consisted  of  ache  or  colics 
in  the  right  upper  abdominal  quadrant  or  toward  the  rib 


118  CANCER  OF  THE  STOMACH 

edges.  They  would  come  on  3  to  4  hours  p.c.  or  at  night 
and  last  until  he  ate  sometliing  or  forced  himself  to  vomit. 
His  appetite  was  generally  good,  but  he  hmited  his  eating 
at  such  times.  Between  the  ''spells"  of  dyspepsia  he  w^as 
perfectly  well.  Six  months  ago  he  began  to  have  rather 
constant  distress  accompanied  by  acid  eructations  and 
some  nausea.  Appetite  became  less  sharp.  One  night 
while  unlacing  his  shoes,  he  felt  ''queer"  and  soon  afterrv^ard 
vomited  about  a  pint  of  red  blood.  Was  in  bed  a  week; 
then  felt  fairly  well  except  for  soreness  in  the  pit  of  his 
stomach.  Since  the  hemori^hage,  has  felt  moderately  com- 
fortable except  for  some  weakness.  Appetite  has  been  a 
bit  capricious.  Bowels  which  were  formerly  constipated 
have  been  loose  for  past  2  weeks.  Xever  noted  blood. 
Thinks  he  is  about  15  to  20  pounds  underweight. 

Status  PrcBsens. — ^Moderately  well  nourished,  lanky  male; 
sclera  clear;  tongue  large  and  coated  heavily;  teeth  poor 
and  dirty; /e^or  ex  ore. 

Neck  and  Chest. — Negative. 

Abdomen. — Somewhat  full  in  epigastrium;  tenderness 
with  muscle  spasm  in  right  upper  quadrant  and  at  right 
rib  margin;  nothing  abnormal  palpated. 

Rectal  examination  negative. 

Blood.— Rg.,  85  (Tallq\dst);  r.b.c,  5,340,000;  w.b.c, 
7,000. 

Test-meal. — Total  acidity,  44.  Free  Hcl,  28.  Combined 
acids  and  acid  salts,  10.    No  12-hour  retention. 

Stool. — Trace  of  blood  (benzidin)  on  milk  diet. 

Laparotomy. — Calloused  ulcer  size  of  a  half  dollar  on 
lesser  cur^^ature  in  antral  region;  edges  thickened;  base 
clean;  no  enlargement  of  perigastric  Ijonph  glands;  stomach 
moderately  dilated. 

Operation. — ^Nlikulicz-Hartman,  Billroth  No.  2  with  pos- 
terior gastro-enterostomy. 

Pathologic  Report. — Early  carcinoma  of  glands  of  edge 
and  base  of  ulcer.  Numerous  areas  showing  epithelial 
wandering  through  basement  membrane.  Extensive  round 
cell  infiltration. 

2.  Chronic  Calloused  Prepyloric  Ulcer;  Stenosis;  "Delayed" 
Vomiting;  Laparotomy:  Indurated  Ulcer  on  Lesser 
Curvature;  Microscopically — Adenocarcinoma  with  much 
Scar-tissue: 


SYMPTOMATOLOGY  119 

Miss  N.  McD. — Age  42,  stenographer. 

Family  History. — Negative. 

Personal  History. — Scarlet  fever  twice  when  young  girl; 
many  attacks  of  tonsillitis;  has  severe  headaches  at  irreg- 
ular intervals. 

Present  Illness. — Gives  account  of  ^'stomach  trouble" 
for  23^^  years.  Onset  was  gradual  but  has  never  been  free 
from  dyspepsia  since  ailment  began;  has  been  worse  for 
past  6  months. 

Complaint. — Pain.  Is  located  in  epigastrium,  especially 
in  right  upper  quadrant.  Character  is  ''gripping"  and 
aching;  maximum  distress  is  generally  2  to  3  hours  p.c.  or 
at  night.  There  is  no  transmission  of  pain.  Vomiting, 
diet  and  alkalies  give  relief;  lying  on  left  side,  jolting  or 
body  movements  aggravate  pain. 

Vomiting. — Began  11  months  ago;  for  3  to  4  weeks 
vomited  after  every  meal,  usually  between  10  and  11  a.m. 
Eating  or  ''crampy"  pain  appeared  to  precipitate  vomiting. 
Later  began  to  vomit  at  bed-time;  material  vomited  fre- 
quently contained  food  eaten  at  breakfast.  Vomitus  was 
''blackish"  once.  Always  felt  relieved  after  vomiting. 
For  past  6  months  has  vomited  rarely  up  to  1  week  ago. 
At  that  time  had  sharp  epigastric  pain  and  vomited  until 
stomach  was  entirely  empty;  noted  no  blood  in  either 
vomitus  or  stool.     Has  been  on  liquid  diet  since. 

Regurgitation,  pyrosis  and  water-brash  very  annoying; 
came  on  mainly  at  night. 

Appetite.- — Good  desire,  but  afraid  to  eat. 

Bowels. — Always  costive. 

Weight. — Eleven  months  ago  lost  40  pounds;  gained  20 
pounds  and  held  it  to  2  months  ago;  is  now  25  pounds 
under  normal  weight. 

Menopause. — Eleven  months  ago. 

Status  PrcBsens. — Rather  poorly  developed  maiden  lady 
but  fairly  well  nourished.  Skin  dry  and  loose;  sallow. 
Sclera  clear;  mucosae  pale;  tongue  coated;  teeth  in  fair  state 
of  repair. 

Head,  Neck  and  Chest. — -Negative. 

Abdomen. — Somewhat  scaphoid.  Abdominal  aorta  pul- 
sated visibly  and  violently.  Palpation:  Tenderness  in 
mid-epigastrium  with  slight  rigidity  of  right  rectus  mus- 
cle.   Stomach,  splashy. 


120  CANCER  OF  THE  STOMACH 

Vaginal  and  Rectal  Examinations. — Negative. 
Laboratory  Findings: 

Blood.— Kg.,  70;  r.b.c,  4,020,000;  w.b.c,  10,600. 

Test-meal. — Twelve-hour  retention.  Total  acidity,  68; 
free  Hcl,  40.  No  blood.  Microscopically,  yeasts  and 
small  type  sarcinae. 

Urine. — Negative. 

Laparotomy. — Calloused  ulcer  involving  the  pylorus  and 
lesser  curvature  in  antral  region;  ulcer  4  cm.  in  diameter; 
no  gland  involvement;  diverticulum  1}4  cm.  in  diameter  is 
seen  on  jejunum  about  1  meter  from  the  pylorus. 

Operation. — Pj^lorectomj^ ;  posterior  gastro-enterostomy. 

Pathologic  Report. — Indurated  ulcer  with  adenocarcinoma 
in  edges  and  base. 

3.  Acute  Onset;  Rapid  Course;  Hemorrhage  Early;  Weight 
Loss;  Calloused  Ulcer  at  Laparotomy;  Malignant  Micro- 
scopically: 

Mr.  J.  S. — Age  65,  Swedish,  laborer. 

Family  History.- — Negative. 

Personal  History. — Always  well  up  to  onset  of  present 
trouble. 

Present  Trouble. — Three  months  ago  had  sudden  and 
severe  epigastric  pain  following  food  ingestion.  Since 
then  has  never  felt  himself.  Pain  comes  on  immediately 
after  eating  and  lasts  about  4  hours;  then  it  is  relieved  by 
vomiting.  Recently  pain  has  been  particularly  severe  at 
night  between  12  m.  and  3  a.m.  Cannot  sleep  until  he 
vomits. 

Vomiting.- — Three  to  8  hours  folloT\4ng  meals;  vomitus 
consists  of  undigested  food  and  blood.  Is  constantly 
nauseated. 

Appetite. — Very  poor;  is  on  milk  diet. 

Weight. — Thirtj^  pounds  loss  in  3  months. 

Bowels. — Constipated  for  past  25  years. 

Urine. — Peculiar  odor. 

Status  Prcesens. — Aloderately  well  developed,  but  soft 
tissues  flabby.  Color,  good;  skin,  soft  and  smooth;  sclera, 
clear;  tongue,  clean;  teeth,  fair  but  dirty. 

Head,  Neck  and  Chest. — Negative. 

Abdomen. — Negative  except  for  slight  tenderness  in  upper 
epigastrium. 


SYMPTOMATOLOGY  121 

Rectum. — Negative. 

Blood.  — Hg.,  80  per  cent. 

Test-meal. — ^Moderate  12-hour  retention;  blood-tinged 
gastric  extract.  Total  acidity,  58;  free  Hcl,  34;  blood+ 
(benzidin  test).  ^licroscopically,  few  budding  yeasts  and 
red  blood  cells;  many  short,  fat  rods  (colon  baciUi). 

Stool.- — Blood+  (benzidin  test). 

Laparotomy. — A  hard  indurated  ulcer  on  the  anterior 
wall  and  the  upper  surface  of  the  pylorus;  partial  pyloric 
stenosis;  moderately  dilated  stomach;  no  perigastric  lymph- 
gland  invoh^ement. 

Operation. — Pylorectomy ;  posterior  gastro-enterostomy. 

Pathologic  Report. — Indurated  gastric  ulcer;  much  scar- 
tissue;  in  base  are  areas  of  adenocarcinoma. 

4.  Short  Duration;  Few  Symptoms,  Hemorrhage;  Malignant 
Anterior  Wall,  Ulcer: 

Mr.  P.  L.,  age  66,  German,  lumber  dealer. 

Family  History. — Mother  died  of  a  malignant  growth  of 
the  phar\'nx. 

Personal  History. — Always  well  to  6  months  ago,  when 
he  began  to  have  abdominal  fulness,  particularly  after 
eating,  belched  much  gas.  No  pain  or  vomiting;  occasion- 
ally nausea.  Appetite  and  bowels  normal.  One  week 
ago  had  severe  abdominal  cramps.  Was  nauseated  and 
could  not  get  bowels  to  move.  The  next  day  passed  a 
large  amount  of  black  blood  by  rectum.  Has  had  no 
recurrence. 

Weight. — Thinks  perhaps  10  pounds  below  normal. 

Status  Prcesens. — Well  nourished;  good  color;  tongue 
clear. 

Head,  Neck  and  Chest. — Negative. 

Abdomen. — Spasm  in  mid-epigastrium  on  palpation. 

Rectal. — Negative. 
Laboratory  Examinations: 

Blood.— Kg.,  85. 

Test-meal. — No  retention.     Free  Hcl,  26.     No  blood. 

Stool. — Blood+  (benzidin). 

Laparotomy. — Calloused  ulcer  on  anterior  surface  of 
stomach  4  cm.  from  pylorus;  no  glands  involved;  serous 
surface  adherent;  cholecystitis. 


122  CANCER  OF  THE  STOMACH 

Operation. — Partial  gastrectomy;  posterior  gastro-enter- 
ostomy;  cholecystostomy. 

Pathologic  Report. — Indurated  ulcer.  Adenocarcinoma 
in  edges  and  base;  moderate  amount  of  scar-tissue. 

Group  II.  Gastric  Cancer,  Clinically  Developing  in  Patients  with  Years  of 
Antecedent  "Dyspepsia"  of  the  Peptic  Ulcer  Type 

Our  series  demonstrates  that  this  group  includes  the 
majority  of  cases  of  gastric  carcinoma.  There  were  436 
instances  (47.3  per  cent.)  where  patients  appeared  with  a 
gastric  ailment  evidently  malignant  that  had  been  super- 
imposed upon  a  previously  benign  type  of  dyspepsia.  The 
form  of  antecedent  gastric  malfunction  satisfied  the  com- 
monly accepted  clinical  complex  of  chronic  peptic  ulcer. 
The  disturbance  readily  divides  itself  into  two  strikingly 
different  periods :  one  benign  and  usually  long  drawn  out, 
and  the  other  malignant,  continuous  and  progressing 
relentlessly  toward  a  fatal  issue.  The  anamnesis  alone 
brings  ou.t  the  characteristics  of  the  disease  in  each  of  its 
stages. 

It  is  becoming  more  generally  recognized  that  gastric 
diagnosis  gains  in  accuracy  in  proportion  to  the  diligence 
with  which  enquiry  is  made  into  the  departures  from  proper 
stomach  functioning  previous  to  those  which  exist  at  the 
time  when  the  patient  appears  for  a  solution  of  his  dyspeptic 
dilemma.  Accidental  complications  often  of  a  mechanical 
nature  not  infrequently  cause  the  gastric  case  to  seek  a 
doctor's  aid.  It  is  only  by  disengaging  the  patient  (and 
often  his  physician)  from  the  present  state  and  endeavoring 
to  determine  and  analyze  his  early  departure  from  gastric 
health  that  one  is  able  to  accurately  judge  what  sequence 
of  clinical  events  led  up  to  the  immediately  existing 
digestive  anomaly. 

Study  of  our  material  has  by  no  means  shown  that 


SYMPTOMATOLOGY  123 

gastric  cancer  most  commonly  attacks  individuals  whose 
stomachs  had  previously  been,  as  Napoleon  told  his 
physician  Automanchi  ''Uke  iron."  On  the  contrary,  the 
great  number  of  these  so-called  ferruginoid  stomachs 
have  an  important  etiologic  history  behind  them,  even  as 
did  the  classic  gut  of  Napoleon.  For,  as  we  inquire  into 
the  early  history  of  this  oft-cited  case,  we  find  abundant 
evidence  that  the  imperial  stomach  rebelled  quite  regularly 
and  sometimes  disastrously  {vide  battle  of  Leipsic.) 

(a)  The  Precarcinomatous  Period. — The  average  dura- 
tion of  all  symptoms  in  the  first  stage  of  the  ailment, 
that  clinically  benign,  w^as  10.5  years.  The  shortest 
history  of  this  phase  extended  over  2  years  and  the  longest 
more  than  45  years.  This  long  antecedent  history  of 
gastric  malfunction  proves  that  the  majority  of  our  cases 
of  gastric  cancer  did  not  develop  in  patients  who  had  pre- 
viously been  in  good  gastric  health.  The  interpretation, 
clinically,  that  we  place  upon  the  nature  of  the  early  dyspep- 
sia, depends,  naturally,  upon  the  conception  which  experi- 
ence has  given  us  regarding  symptomatology  of  gastric 
disease,  the  value  of  facts  making  up  the  histories,  and  our 
observations  of  the  subsequent  course  of  the  ailment. 

The  point  of  greatest  import  in  the  consideration  of  the 
precarcinomatous  picture  of  the  disease,  is,  that  while 
certain  histologic  changes  of  a  malignant  type  may  have 
lain  latent  in  the  gastric  wall  for  years,  it  was,  at  this  first 
period,  impossible  to  recognize  such,  clinically. 

Symptomatically,  this  early  period  of  the  ailment  satisfies 
the  accepted  clinical  complex  which  we  associate  with 
chronic,  recurrent  gastric  ulcer.  This  statement  does  not 
imply  that  the  majority  of  gastric  ulcers  become  cancers; 
it  is  simply  a  statement  indicating  that  the  greatest  number 
of  our  proved  cases  of  gastric  cancer  had  had  gastric  ulcer 


124  CANCER  OF  THE  STOMACH 

symptoms  prior  tO  the  time  when  their  dyspepsias  assumed 
maUgnant  features.  No  one  can  offer  opinion,  based  upon 
actual  facts,  as  to  the  percentage  of  ulcers  that  undergo 
malignant  transformation.  Doubtless  many  ulcers  heal 
or  remain  benign.  The  caution  should  be  strongly  urged, 
however,  that  in  every  gastric  ulcer  there  exists  the  anlage 
of  a  future  cancer,  and  that  only  by  recognition  of  this 
possibility  and  by  constantly  watching  the  progress  of 
individuals  thus  affected  (especially  as  they  pass  beyond 
the  fourth  decade  of  life)  can  we  hope  to  be  of  any  actual 
service  to  those  individuals,  or  to  the  race,  with  respect  to 
cure  or  prevention  of  gastric  malignancy. 

The  symptomatology  of  the  precarcinomatous  period  is 
in  every  way  similar  to  that  above  outlined  as  comprising 
the  whole  course  of  cases  making  up  Group  I.  It  is  not 
necessary  to  repeat  it.  The  cases  give  typical  ulcer 
histories.  And,  indeed,  if  such  patients  come  to  lapar- 
otomy at  any  time  during  this  clinically  benign  stage, 
ulcers  without  evidence  of  malignant  hyperplasia  are 
demonstrated  surgically  and  often  pathologically. 

Briefly,  the  study  of  this  early  dyspeptic  disturbance, 
"established  the  following  facts  in  our  material : 

Attacks  or  "spells"  of  indigestion  occurred  in  82  per 
cent,  of  instances.  Seasonal  relationship  was  not  in- 
frequently demonstrated.  Over-work,  exposure  and  inter- 
current infectious  diseases  appeared  to  play  a  consider- 
able r61e  in  precipitating  or  aggravating  symptoms.  These 
''spells"  of  dyspepsia  were  characterized  by  epigastric 
distress  or  actual  pain  in  392  cases  (90  per  cent.).  In  366 
instances  (84  per  cent.)  the  abdominal  distress  bore  definite 
relation  to  the  taking  of  food.  Until  complications  super- 
vened, this  "food  relief"  of  pain  was  quite  constant  and 
characteristic.     Other  forms  of  pain  relief  were  alkalies, 


SYMPTOMATOLOGY  125 

diet  or  vomiting.  Pain  was  generally  located,  sympto- 
matically,  in  the  upper  two-thirds  of  the  epigastrium.  In 
270  cases  (62  per  cent.)  pain  had  a  point  of  maximum 
intensity.  This  was  most  frequently  located  at  or  sHghtly 
to  the  right  of  the  mid-hne.  In  224  patients  (51.4  per 
cent.)  pain  was  referred  to  some  part  of  the  back.  The 
areas  of  referred  distress  were  most  commonly  between 
the  shoulders  or  to  one  or  both  scapular  regions. 

Food  desire  was  usually  strong,  but  appetite  suffered 
from  fear  of  precipitating  digestive  upsets  by  eating. 

Weight  was  not  infrequently  lost  in  these  attacks  of 
limited  food  intake,  only  to  be  gained  again  when  qui- 
escence supervened.  The  average  weight  loss  was  15.8 
pounds. 

Constipation  was  noted  in  209  instances  (48.2  per  cent.). 
Twenty-seven  patients  (6.5  per  cent.)  had  experienced 
diarrhea  at  some  time  during  this  precarcinomatous 
period. 

Vomiting  was  recorded  in  265  cases  (63  per  cent.).  In 
217  of  these  patients  who  vomited  (82  per  cent.),  the  emesis 
was  periodic.  Retention  vomiting  was  noted  in  98  cases 
(37  per  cent.). 

Bleeding  (hematemesis  or  melena)  was  a  sign  in  92 
instances  (21  per  cent.),  during  this  stage  of  the  disease. 
Of  those  bleeding,  47  cases  (50.6  per  cent.)  had  experienced 
hemorrhage  at  least  2  years  before  the  time  when  they 
came  under  observation.  Of  those  instances  (45)  where 
bleeding  had  occurred  more  recently  than  2  years,  28 
(62  per  cent.)  were  patients  whose  dyspeptic  history  was 
longer  than  10  years. 

Anemia  was  rarely  marked  in  the  chnically,  benign  ulcer 
stage.  The  average  hemoglobin  was  approximately  75 
per  cent. 


126  CANCER   OF   THE    STOMACH 

Before  proceeding  to  a  study  of  the  second  (malignant) 
phase  of  this  class  of  patient  we  would  emphasize  the  group 
type  by  the  following  histories. 

1.  Long  Dyspeptic  History;  Ulcer  Type;  Early  Hemorrhage, 
Supervening  Malignancy;  Free  Abdominal  Fluid: 

Mr.  A.  L. — Age  52,  German,  carpenter. 
Family  History. — Negative. 

Personal  History. — Married  twice,  first  wife  died  of 
tuberculosis. 

Present  Trouble. — Periodic  dyspepsia  from  18  to  21  years 
of  age;  this  consisted  of  epigastric  pain,  sour  eructations 
and  belching,  and  occasionally  vomiting  of  sour  fluid. 
At  age  22  vomited  about  a  pint  of  blood;  was  in  bed  2 
weeks;  since  then  has  had  only  rare  attacks  of  the  dys- 
pepsia until  17  months  ago.  He  then  began  to  have  pain 
in  the  epigastrium.  This  was  a  gnawing  and  sore  feeling 
and  was  worse  about  2  hours  after  eating.  Shortly  after- 
ward he  began  to  vomit.  Recently  has  had  night  pain, 
with  vomiting  about  1  o'clock  in  the  morning.  He  fre- 
quently vomits  up  what  he  had  eaten  for  breakfast,  and 
occasionally  material  eaten  the  day  previously. 

Weight  Loss. — Fifty  pounds  in  6  months. 

Physical  Examination. — Much  emaciated,  sallow  com- 
plexion, skin  dry;  weak  and  tired-looking;  tongue  coated. 

Thorax. — Negative. 

Abdomen. — Moderately  distended;  small  umbilical  her- 
nia; inguinal  glands  moderately  enlarged.  Percussion 
dulness  in  flanks,  movable.     No  abdominal  tumor  palpable. 

Rectal  Examination. — Negative.     Liver  and  spleen,  not 
enlarged. 
Laboratory  Examinations: 

Blood.— B.g.,  82  per  cent.;  r.b.c,  4,980,000;  w.b.c,  6,200. 

Test-meal. — Total  acidity,  28;  free  Hcl,  12;  combined 
acids,  8;  altered  blood+.     Moderate  12-hour  retention. 

Microscopically. — Oppler-Boas  bacilU  (?).     Yeasts. 

Stool. — Altered  blood+  (benzidin  test).  Schmidt  bi- 
chlorid  test :  hydrobilirubin. 

Laparotomy. — ^Long  right-rectus  incision.  About  2,000 
cc.  of  serofibrinous  peritoneal  fluid.  Large  carcinoma  in- 
volving greater  curvature,  with  extension  into  pancreas. 
Secondaries  in  liver. 


SYMPTOMATOLOGY  127 

Operation. — Exploratory. 

Pathologic  Report. — Gland  removed  shows  carcinoma. 

2.  Previous  History  Suggesting  Ulcer  at  the  Cardia  Followed  by 
Partial  Malignant  Stenosis;  Young  Patient: 

Mrs.  H.  S. — Age  26,  Finnish,  housewife. 

Family  History. — Negative. 

Past  History. — Negative. 

Present  Trouble. — Dm'ing  the  past  5  years  has  had  at- 
tacks of  high  epigastric  pain  coming  on  immediately  after 
eating,  and  accompanied  by  vomiting  of  food  that  has  been 
eaten  shortly  before.  Sour  stomach  and  acid  eructations 
have  been  prominent  in  these  attacks.  Had  no  alteration 
in  the  symptoms  until  3  or  4  months  ago  when  noticed  that 
solid  food  seemed  to  stick  in  the  esophagus  and  would  cause 
pain  lasting  from  3^  to  1  hour  after  eating.  Relief  of  dis- 
tress was  obtained  by  forced  vomiting.  During  the  past  6 
weeks  the  pain  has  been  constant,  and  has  been  accom- 
panied by  constipation  and  marked  vomiting  if  patient  is 
on  ordinary  diet.  Recently  pain  has  been  very  marked  in 
the  ''small  of  the  back." 

Appetite. — Good,  but  afraid  to  eat  on  account  of  pain. 

Bowels. — Very  constipated. 

Weight. — Has  lost  26  pounds  in  about  3  months. 

Examination. — Patient  poorly  nourished;  skin  pale  with 
acne-like  eruption  over  face.  Tongue  coated;  teeth  dirty; 
breath  heavy. 

Thorax. — Negative. 

Abdomen. — Flat;  general  tenderness  in  epigastrium;  at 
the  left  costal  arch  a  slightly  movable  tumor  is  palpated 
toward  the  pit,  no  tenderness. 

Vaginal  Examination. — Negative. 
Laboratory  Examination: 

Blood. — Hg.,  40  per  cent.  (Dare). 

Test-meal. — Tube  met  resistance  at  cardia.  There  fol- 
lowed free  bleeding.  No  contents  obtained.  Microscopic 
examination  of  blood  clots  in  end  of  stomach  tube  showed 
chains  of  streptococci;  many  red  blood  cells  and  large, 
partly  disintegrated,  epithelial  cells. 

Stool. — Altered  blood-f-  (benzidin  test). 

Laparotomy. — High  median  incision.  At  the  cardiac 
end  of  the  stomach  is  a  carcinomatous  mass  encircling  the 


128  CANCER   OF   THE    STOMACH 

orifice;  it  is  very  hard  and  about  %  of  an  inch  broad.  The 
cardiac  lumen  barely  admits  a  little  finger.  The  cardiac 
glands  are  greatly  hypertrophied. 

Operation. — Exploratory;  appendicectomy. 

Pathologic  i^eporL— Gland  from  near  cardia.  Adeno- 
carcinoma with  much  scar-tissue. 

3.  Carcinoma  Following    Ulcer  History:  Hemorrhages;   Ob- 
struction: 

Mr.  R.  J. — Age  48,  Swede,  stone  mason. 

Family  History. — Negative. 

Personal  History. — Pneumonia  3  years  ago,  otherwise 
well;  denies  venereal. 

Present  Illness. — Gastric  disturbance  for  6  years.  Com- 
plaint usually  epigastric  pain,  coming  on  generally  2  hours 
after  eating  and  most  severe  just  before  eating.  Food 
intake  promptly  relieved  pain.  Pain  transmitted  to  right 
upper  abdominal  quadrant  and  to  back,  between  shoulders. 
Frequently  awakened  at  night  by  pain.  Body  movement 
aggravated  distress.  Usually  worse  in  fall  and  has  periods 
of  remission. 

Present  Trouble. — Three  weeks  ago  became  nauseated 
and  vomited  about  a  cupful  of  blood.  Never  vomited 
before  or  since.  Since  then  has  had  constant  belching, 
pyrosis  and  has  noted  since  then  that  stools  have  been 
blackish  in  color.  Pain  has  diminished  in  intensity,  bat 
has  become  constant. 

Appetite. — Poor;  strength  reduced. 

Weight. — ^Lost  42  pounds  in  less  than  a  month. 

Physical  Examination. — Well  developed,  but  poorly 
nourished.  Sallow  color;  tongue  coated.  Post-malleolar 
edema;  skin  loose  and  dry. 

Head,  Neck  and  Chest. — Negative. 

Abdomen. — Marked  rigidity  of  both  recti  muscles,  par- 
ticularly on  left  side.     Stomach  dilated,  great  curvature 
extends  2  f.b.  below  navel. 
Laboratory  Examination: 

Blood.— B.g.,  65;  r.b.c,  3,400,000;  w.b.c,  12,000. 

Test-meal. — Twelve-hour  retention.  Total  acidity,  76; 
Hcl,  trace;  lactic  acid-h;  altered  blood-f;  Wolff  test-j-  (400 
units  of  precipitable  albumin) ;  pepsin  and  rennin,  trace. 

Stool. — Altered  blood  +  (guaiac  test). 


SYMPTOMATOLOGY  129 

Urine. — Albumin  trace;  few  coarse  granular  casts. 

Laparotomy. — Carcinomatous  mass,  10  cm.  in  circum- 
ference, on  lesser  curvature;  glands  involved. 

Operatio7i. — Exploratory. 

Pathologic  Report. — Gland  from  lesser  curvature:  adeno- 
carcinoma. 

4.  Gradual  Onset,  Ulcer  Sympto7ns,  Early  Vomiting,  Recent 
Rapid  Weight  Loss;  Carcinoma  of  Pylorus  loith  Large 
Cardiac  Glands: 

Mrs.  M.  B. — Age  48,  German,  housewife. 

Family  History. — Negative. 

Past  History. — Three  years  and  6  months  ago,  began  to 
regurgitate  food  soon  after  eating.  This  seemed  to  be 
caused  by  a  burning  pain  extending  from  the  ensiform  to 
the  base  of  the  tongue.  Was  worse  after  hesivj  meals. 
Much  sour  regurgitation,  nausea  and  pj^rosis.  Xever 
vomited  blood,  but  frequently  large  amounts  of  partly 
changed  food.  A  few  months  afterward  noted  a  pain  in  the 
left  costal  arch.  It  came  on  at  once  after  eating,  and  was 
quite  severe.  Has  been  fairly  constant  since.  Took  ulcer 
cure  in  a  hospital.  At  present  there  is  much  gas  and  bloat- 
ing for  3  or  4  hours  after  meals  when  patient  is  relieved 
by  vomiting.  Of  late  some  difficulty  in  swallo'^dng  large 
pieces  of  food;  they  seem  to  stick  at  the  pit  of  the  stomach. 

Appetite. — Has  been  poor. 

Bowels. — Constipated  and  stools  of  offensive  odor. 

Weight. — Has  lost  115  pounds  in  6  months. 

Physical  Examination. — ^Markedly  emaciated;  skin  sal- 
low; looks  cachectic;  slight  edema  about  the  ankles;  teeth 
very  poor;  tongue  coated;  breath  foul. 

Chest. — Negative. 

Abdomen. — Xo  palpable  tumor;  tenderness  to  left  of 
navel;  stomach  splashy. 

Vaginal  Examination. — Negative. 

Blood.— Rg.,  60;  r.b.c,  3,600,000;  w.b.c,  8,400. 

Differential  White  Cell  Count. — Pol^niuclears,  77.3  per 
cent. ;  smaU  lymphocytes,  20.7  per  cent. ;  large  lymphocytes, 
1.1  per  cent.;  transitionals,  0.7  per  cent.;  eosinophiles, 
0.3  per  cent.;  1  normoblast  seen. 

Test-meal. — Stomach  tube  meets  resistance  at  cardia; 
no  bleeding.  Gastric  extract  tan-brown  in  color,  food 
poorly   chj-mified;   somewhat   rancid   odor,   moderate   12- 


130  CANCER  OF  THE  STOMACH 

hour  retention.  Total  acidity,  34;  free  Hcl,  0;  lactic 
acid+;  altered  blood+. 

Stool. — Small,  mushy,  light  brown.     Altered  blood+. 

Laparotomy. — High  right  rectus  incision.  Tumor-mass 
the  size  of  a  croquet-ball  involves  the  pylorus  and  antrum 
posteriorly.  Tumor  is  freely  movable;  peripyloric  glands 
enlarged.  Very  marked  enlargement  of  glands  at  the  car- 
dia,  especially  where  the  gastric  artery  meets  the  lesser 
curvature. 

Operation. — Partial  gastrectomy;  posterior  gastroenter- 
ostomy. 

Pathological  Report. — Diffuse  infiltrating  carcinoma. 

(b)  The  Clinically  Carcinomatous  Period. — The  pre- 
ceding histories  convey  a  fairly  representative  impression 
of  the  sequence  of  events  leading  up  to  a  malignancy  from 
a  clinically  benign  affection.  The  change  in  the  character 
of  the  disease  is  often  a  very  gradual  one.  When  we  recall 
the  pathologic  alterations  that  are  going  on  in  the  ulcer 
areas  in  these  cases,  it  would  seem  quite  reasonable  that  a 
neoplasm  should  well  establish  itself  before  it  could  be  ex- 
pected to  give  any  definite  clinical  warning  of  its  existence. 

When  we  analyze  the  mode  of  onset  of  the  apparently 
malignant  stage  of  the  dyspepsia  we  are  impressed  by  the 
great  number  of  ways  in  which  the  patient  or  his  medical 
attendant  are  made  aware  that  some  sort  of  alteration  in 
the  ailment  is  in  progress.  Bleeding,  constant  nausea, 
vomiting,  gassy  distention,  persistent  abdominal  discom- 
fort, loss  of  appetite,  weight  and  strength,  diarrhea  or 
enlarging  abdomen  may  usher  in  the  pernicious  phase  of 
the  disease.  Whatever  may  be  the  form  which  the  new 
type  of  affection  assumes,  the  most  characteristic  manifesta- 
tion is  the  appearance  of  a  continuous  and  progressively 
downward  gastric  disorder  in  an  individual  whose  pre- 
vious dyspepsia  had  been  periodic  (82-1-  per  cent.).  This 
occurs  with  or  without  the  onset  of  pyloric  or  cardiac 


SYMPTOMATOLOGY  131 

obstruction  or  hindrance  to  the  onward  progress  of  food 
by  loculation  of  the  stomach  fiom  a  neoplasm.  Where 
previously  there  was  abdominal  discomfort  in  "spells" 
or  attacks,  frequently  relieved  by  food  or  medicines,  one 
observes  food  aggravation  of  such  distress,  persistent 
night  pain,  delayed  vomiting,  continuous  presence  of  altered 
blood  in  the  stools,  diarrhea,  anorexia,  weight  loss  steadily 
maintained,  weakness,  anemia,  peripheral  edema,  cachexia, 
sallow,  di-y,  scaly  skin,  lack-luster  eye  and  a  peculiar  hope- 
less apathy  reflected  in  the  face.  There  often  seems  to  be 
a  sense  of  impending  evil.  ^Nlelanchohc  symptoms  may 
not  be  lacking.  Introspective  mental  attitudes  may  be 
estabUshed  in  individuals  who  prevdously  had  been  cheerful 
and  optimistic.  Rarely,  suicidal  tendencies  are  exhibited. 
While  the  above  is  the  common  clinical  picture  presented 
as  cancer  intoxication  evidences  itself,  no  especial  change 
may  be  observed  ^particularly  by  a  busy  indi\ddual  with 
large  interests)  until  an  epigastric  nodule  or  loose  clothing 
bring  him  to  a  physician  for  an  explanation.  Not  infre- 
quently patients  attribute  an  unexplainable  vague  ''queer- 
ness"  to  over-work,  physical  or  mental,  and  seek  rehef 
through  the  medium  of  a  hohday,  osteopathy,  ''christian 
science,"  patent  ''tonics,"  and  such  ever-baited  snares, 
only  to  appear  some  months  afterward  with  an  extensive 
and  hopeless  malignancy.  It  is  often  astonishing  how 
child-hke  may  be  the  mental  processes  of  otherwise  mature 
and  brilhant  brains,  when  such  occupy  themseh'es  with  the 
consideration  of  bodily  ills.  Hence,  the  class  of  patients  in 
whom  gastric  mahgnancy  has  its  mild  beginnings,  most 
frequently  come  to  a  physician  when  the  disease  is  farthest 
advanced.  'V\lien  constant  pain,  vomiting  or  diarrhea  are 
suffered  early  they  often  serve  a  useful  purpose.  Such 
patients  consult  the  physician  earliest :  the  science  and  art 


132  CANCER  OF  THE  STOMACH 

of  charlatan,  the  ''wise"  neighbor  and  the  cure-all  almanac 
are  soon  exhausted. 

Duration  of  tJie  Malignant  Period. — At  the  time  when 
patients  came  under  observation,  they  had  been  affected 
with  an  evidently  cancerous  process  for  an  average  time  of 
6.3  months.  In  other  words,  more  than  a  half  year  was 
consumed  by  the  growing  neoplasm  in  making  it  evident 
to  the  patient,  or  his  advisers,  that  he  was  not  having  a 
recurrence  of  his  former  dj^speptic  disturbance.  ^Tien  we 
reflect  that  more  than  4  out  of  5  such  patients  had  a 
continuous  gastric  malfunction  succeed  one  previously 
'periodic,  it  is  quite  e^ddent  that  either  the  onset  of  the 
ailment  has  been  insiduous  or  that  professional  advice  has 
been  timid  or  uncertain.  ^Meanwhile  the  growth  of  the 
cancer  has  progressed  so  extensively  that  in  but  one- 
third  of  all  our  cases  of  the  disease  were  the  surgeon  and 
the  patient  given  the  advantage  of  a  locaUzed  ailment 
when  laparotomy  was  performed.  Early  abdominal  ex- 
ploration of  the  chronic  dyspeptic  at  the  cancer  age  is  the 
only  way  to  change  such  experience. 

Abdominal  Pain. — In  but  74  of  the  cases  (17  per  cent.) 
comprising  Group  II  was  severe  pain  a  complaint.  It  was 
usually  described  as  ''raw" — "sore" — "duU,  heavj^  ache" 
or  "cramps."  In  51  instances  (11.6  per  cent.)  opiates 
were  required  to  give  relief  of  distress.  "Gassy"  and 
"bloated"  sensations  were  quite  generally  complained  of, 
particularly  when  the  new-growth  involved  the  orifices, 
and  food  was  retained  in  either  stomach  or  esophagus. 
Rarely  was  "food  reUef  "  of  abdominal  discomfort  observed. 
Food  aggravation  was  the  rule.  WTiile  intensity  of  pain 
was  usually  less  than  a  given  individual  had  suffered  at 
some  time  in  his  premahgnant  history,  j^et  the  con- 
stancy of  the  distress  frequently  proved  very  annoying  and 


SYMPTOMATOLOGY  133 

exhausting.  This  was  particularly  the  case  where  night 
pain  prevented  sleep  or  where  aggravation  of  gastric 
discomfort  prevented  the  taking  of  proper  nourishment. 

There  was  rarely  a  point  of  maximum  epigastric  distress. 
The  complaint  was  commonly  of  a  diffuse  or  general 
pain.  In  35  cases  (8  per  cent.)  in  addition  to  epigastric 
discomfort,  pains  referred  to  the  back,  rib-edges,  and  the 
legs  were  recorded.  Aggravation  of  abdominal  pain 
by  body  movements  was  noted  in  48  cases  (11  per  cent.). 
The  common  modes  of  pain  relief  in  the  order  of  their 
usefulness  proved  to  be  vomiting,  diet,  lavage,  alkalies, 
opiates  and  rest.  In  certain  instances  the  resourcefulness 
of  the  medical  attendant  was  sorely  taxed  after  the  ex- 
hibition of  all  these  remedies. 

Vomiting. — This  symptom  occurred  in  390  instances  (89 
per  cent.)  when  malignancy  supervened  upon  what  had 
been  a  clinically  benign  process.  In  315  cases  (74  per  cent.) 
the  vomiting  was  of  almost  daily  occurrence. 

Vomitus  was  more  copious  in  this  phase  than  previously. 
Not  infrequently  several  quarts  of  material  were  raised. 
The  odor  of  the  vomitus  was  quite  characteristic  in  mod- 
erately advanced  cases.  Whereas  this  had  commonly 
been  of  a  sour  or  yeasty  odor  in  the  earlier  months  or 
years  of  the  affection,  when  malignancy  was  established 
the  odor  most  frequently  was  cheesy,  rancid  or  pene- 
tratingly pungent.  When  sloughs  of  cancer  tissue,  de- 
composed blood  or  contents  of  adjacent  viscera  were  pres- 
ent as  result  of  fistulse,  the  sickening,  foul  odor  was  almost 
pathognomonic . 

The  color  of  the  vomitus  ranged  from  white  to  dark 
brown  or  black.  The  color  was  imparted  by  decom- 
posing food,  blood  or  tissue.  In  but  88  cases  (20.2  per 
cent.)  was  the  vomitus  "coffee  colored,"  as  is  so  often  de- 


134  CANCER  OF  THE  STOMACH 

scribed  in  connection  with  gastric  cancer.  When  vomitus 
of  ^this  color  was  observed,  the  disease  was  far  advanced  in 
83  per  cent,  of  instances  and  irremovable  surgically  in 
more  than  3  out  of  4  such. 

Excess  of  mucus,  chunks  of  poorly  chymified  food  and 
(rarely)  blood-clots,  tissue  sloughs  or  puree-like,  evil- 
scented  fluid  composed  the  vomitus. 

Group  III.  Gastric  Cancer  in  Individuals  who  Prior  to  the  Onset  of  a 
Malignant  Disease  had  Enjoyed  Perfect  Gastric  Health 

Symptomatically,  the  patients  comprising  this  group 
satisfy  the  popular  conception  of  what  constitutes  gastric 
cancer  clinically.  But,  in  even  this  class,  wide  variations 
in  symptomatology  are  possible.  What  is  commonly  de- 
scribed as  gastric  malignancy  is  doubtless  the  picture 
presented,  clinically,  when  affected  individuals  come  for 
examination  as  a  consequence  of  symptoms  arising  from 
mechanical  interference  to  the  easy,  onward  progress  of 
food,  constitutional  evidences  of  a  grave  ailment  or  the 
accidental  discovery  of  an  abdominal  tumor.  In  private 
or  hospital  practice,  but  rarely  is  the  beginning  of  this 
form  of  the  disease  appreciated  or  diagnosed.  As  we 
have  previously  quoted,  the  Fen  wicks  state  that  31  cases 
of  gastric  cancer  entering  their  services  had  previously  been 
ill  for  an  average  time  of  nearly  4  months,  and  this  time 
had  elapsed  apparently  before  such  danger  signals  had  been 
observed  as  to  indicate  a  serious  malady.  The  failure  to 
differentiate  between  disease  entities  and  the  symptoms 
associated  with  such  is  largely  responsible  for  gastric 
cancer  in  its  early  progress  being  clinically  styled  ''acute" 
or  ''chronic gastritis,"  "gastric catarrh,"  "achyliagastrica," 
"chronic  dyspepsia,"  "liver  trouble,"  "nervous  prostra- 
tion" and  the  like.     These  terms  are  not  fanciful:  they  are 


SYMPTOMATOLOGY  135 

such  as  were  actually  given  by  patients  to  describe  the 
early  status  of  their  ailments.  These  ''diseases"  were 
in  the  main,  reflections  of  the  viewpoint  from  which  their 
medical  attendants  considered  their  early  departure  from 
gastric  health. 

While  it  is  true  that  mild  beginnings  characterize  many 
instances  of  this  type  of  carcinoma  of  the  stomach,  it  is  a 
fact  that  the  average  duration  of  early  symptoms  is  of 
sufficient  length  to  permit  a  careful  analysis  of  the  anomaly 
presented.  Here  we  rarely  deal  with  an  emergency.  This 
digestive  or  constitutional  fault  is  certainly  such  as  might 
reasonably  warrant  more  than  passing  attention.  Its 
salient  factors  are  these:  A  dyspepsia  in  an  individual, 
generally  past  middle  age  (at  the  so-called  ''cancer  age"), 
to  whom  such  gastric  disturbance  is  foreign.  The  mal- 
function is  usually  continuous.  It  is  early  manifested  by 
anorexia,  weakness,  anemia,  weight  loss,  cachexia,  pain, 
vomiting,  hemorrhage,  diarrhea  or  abdominal  tumor.  While 
it  is  possible  to  associate  many  of  these  symptoms  with 
benign  gastric  disorders,  the  professional  mental  attitude 
is  seriously  delinquent  which  does  not  regard  all  gastric 
malfunction  in  individuals  past  the  age  of  40  as  malig- 
nant or  potentially  so,  until  it  has  been  definitely  proved 
to  be  benign.  If  pursued  with  common  sense  and  tact, 
this  course  is  quite  possible  without  producing  undue 
apprehension  among  patients.  During  the  past  decade 
there  has  been  such  widespread  popular  education  upon 
malignant  disease  that  reservations  in  diagnosis  are 
often  considered  proper  and  necessary. 

Of  the  921  cases  of  gastric  cancer  forming  the  basis  of 
this  study,  there  were  but  294  instances  (31.9  per  cent.) 
where  a  malignant  gastric  ailment  had  occurred  in  pa- 
tients who  previously  had  experienced    no  gastric  com- 


136  CANCER  OF  THE  STOMACH 

plaint.  The  most  exhausting  anamnesis  failed  to  elicit 
any  symptoms  pointing  to  a  disease  of  the  stomach  before 
an  average  time  of  approximately  7  months  prior  to  the 
patients'  coming  under  observation.  Because  there  had 
been  no  gastric  complaint  previous  to  this  average  figure, 
it  should  be  emphasized  that  one  is  not  justified  in  main- 
taining that  in  such  individuals  there  had  been  no  gastric 
pathology  anteceding  7  months.  On  the  contrary,  the 
not  infrequent  post-mortem  or  laparotomy  discovery  of 
healed  ulcers  or  even  neoplasms  in  subjects  who  have  had 
no  clinical  pointings  referable  to  such  stomach  anomaly 
should  lead  us  to  exercise  caution  with  regard  to  insisting 
when  or  how  malignant  processes  arise  in  the  gastric  wall. 
The  longest  history  of  dyspepsia  in  cases  making  up  this 
group  extended  over  about  S^-i  years;  the  shortest  barely 
2  weeks. 

(a)  Mode  of  Onset. — Many  so-called  "primary"  gastric 
cancers  have  histories  extending  over  weeks  of  time, 
where  the  symptom-complex  closely  approximates  that 
which  is  our  present-day  conception  of  peptic  ulcer,  of  the 
continuously  active  and  progressive  type.  The  clinical 
picture  is  different,  however,  in  one  important  respect.  To 
the  ulcer  symptom-complex  are  early  added  the  mani- 
festations of  a  malignant  systemic  poisoning.  There  is  a 
hurried  progression  through  the  clinical  course  of  ''gastritis" 
and  ''ulcer"  to  a  definitely  malignant  disease.  With 
regard  to  time,  the  whole  course  of  the  ailment  forms  a 
sort  of  "tabloid"  from  which  careful  analysis  readily 
segregates  parts  closely  approximating,  clinically,  those 
stretched  out  over  years  as  exhibited  by  that  great  class  of 
gastric  cancers  making  up  our  Group  II.  The  rapidity 
through  which  these  different  clinical  stages  of  the  disease 
may  be  passed  seems  to  emphasize  the  necessity  for  our 


SYMPTOMATOLOGY  137 

demanding  a  separate  and  not  altogether  unimportant 
recognition  of  the  term  ' '  chronicity "  in  its  pathologic 
sense  and  in  its  time-duration  application  (i.e.,  meaning 
years,  months  or  weeks)  of  the  existence  of  an  ailment. 
It  is  reasonabty  possible  that  the  whole  gamut  of  injury 
to  the  stomach  lining,  local  or  general  gastritis,  ulcera- 
tion and  cancer  may  be  run  in  a  few  weeks  or  months. 
The  rapidity  of  change  occurring  in  experimentally  pro- 
duced tumors  and  in  embryonic,  undifferentiated  tissue 
certainly  would  permit  this  conception  of  the  develop- 
ment of  gastric  cancer.  Such  view  explains  whj^  the 
mode  of  onset  of  ''primary"  gastric  neoplasms  varies 
widely. 

The  onset  in  the  ordinary  case  (there  is  no  ''typical" 
case)  is  rarely  acute.  The  transition  from  complete  gastric 
well-being  is  commonly  gradual.  Aversion  to  certain 
kinds  of  food  (meat,  sweets,  legumes)  or  beverages  (beer, 
coffee,  milk)  is  often  an  early  manifestation.  While  the 
desire  for  some  viands  may  be  keen,  the  aversion  to  others 
may  be  marked  and,  for  the  individual,  radical.  Eructa- 
tions, sometimes  of  disagreeable  taste,  may  be  troublesome 
from  the  first.  Gaseous  distention  of  the  abdomen  is 
frequently  annoying.  Unexplainable  nausea  may  cause 
concern.  Diarrhea  or  diarrheic  stools  appeared  without 
apparent  cause  in  40  of  our  cases  (13.5  per  cent.).  Vomit- 
ing may  be  the  first  symptom  and  its  copiousness,  odor, 
taste  and  color  distressing  and  alarming.  Pain  or  abdom- 
inal discomfort  of  some  degree  is  a  frequent  indica- 
tion that  all  is  not  well.  It  appeared  early  in  214  instances 
(73  per  cent.)  of  this  group.  Sudden  hemorrhage  not 
infrequently  startles  a  pre\dously  well  individual  and  leads 
to  his  seeking  medical  care.  This  happened  in  12  cases 
(4,2  per  cent.),  comprising  this  group.     Again,  rapid  weight 


138  CANCER    OF    THE    STOMACH 

loss,  with  weakness  and  anemia  may  bring  patients  under 
observation. 

The  following  histories  emphasize  certain  features  of 
the  onset  and  course  of  the  disease  in  cases  comprising 
Group  III. 

1.  Gastric    Malignancy    with    Gradual    Onset   and    without 
Severe  Symptoms: 

Mr.  C.  B. — Age  60,  Swedish,  farmer. 

Family  History. — Negative. 

Past  Illness. — Denies  venereal;  had  measles.  Has  been 
constipated  for  15  years,  and  on  account  of  irregular  dys- 
pepsia has  been  taking  medicine  for  past  2  years. 

Present  Complaint. — About  2  years  ago  began  to  lose 
strength  and  weight.  This  was  very  gradual  until  a  year 
ago,  when  appetite  began  to  fail  and  on  account  of  weakness 
patient  was  confined  to  bed  for  2  weeks.  At  the  end  of 
that  time  was  able  to  get  up  and  be  about,  but  did  not  feel 
quite  himself.  Appetite  has  remained  poor  and  for  3 
months  he  has  been  on  liquid  diet.  Food  does  not  distress 
him,  but  more  liberal  diet  causes  vomiting  about  a  half 
hour  after  meals.  Never  vomited  blood.  Never  passed 
blood  in  stools.  For  past  few  months  has  had  vague  sore- 
ness in  epigastrium  but  never  real  pain.  Strength  has 
diminished  and  for  2  weeks  has  had  edema  of  the  feet 
and  ankles.     Recently  constipation  has  become  obstinate. 

Physical  Examination. — Poorly  nourished;  moderate  ane- 
mia; 20  pounds  under  weight;  skin  dry  and  scaly;  edema 
almost  to  knees. 

Chest. — Negative  except  for  slight  cardiac  arrhythmia. 

Abdomen. — ^Liver  dulness  extends  2  finger  breadths' 
below  level  of  ribs  in  nipple  Hne.  On  palpation,  a  mass 
may  be  made  out  running  from  2  finger  breadths'  below  the 
ensiform  cartilage  to  the  left  and  just  below  the  navel.  It 
moves  downward  on  deep  inspiration.  No  adenopathy. 
Laboratory  Examinations: 

Blood.— Kg.,  65  per  cent.  (Dare);  r.b.c,  3,800,000; 
w.b.c,  11,600. 

Test-meal. — Total  acidity,  36;  free  Hcl,  0;  combined 
acid,  18;  lactic  acid  4- ;  altered  blood + (benzidin  test) ;  formol 
index,  26  (Sorenson-Schiff  method).     Moderate  retention. 


SYMPTOMATOLOGY  139 

Microscopic  Examination. — Bacilli  of  the  Oppler-Boas 
type;  few  chains  of  streptococci;  few  small  yeast  colonies. 

Stool. — Altered  blood+  (benzidin  test) — on  milk  diet. 

Laparotomy. — High  right  rectus  incision;  carcinoma 
involving  the  greater  curvature,  pylorus  and  one-half  of 
lesser  curvature.  Secondaries  in  the  liver.  Peritoneum 
extensively  involved  with  masses  resembling  fish-eggs. 

Opera/^on.— Explored  only. 

Pathologic  Report. — Nodule  from  peritoneum  shows  car- 
cinoma of  encephaloid  type. 

2.  Carcinoma  Developing  without  Previous  Gastric  Mal- 
function; Diarrhea  at  Onset: 

Mrs.  M.  L. — Age  50,  Norwegian,  housewife. 

Fainily  History. — Negative.  First  husband  died  of  pul- 
monary tuberculosis;  tlii'ee  children  well  and  strong;  no 
miscarriages;  has  alwaj^s  performed  hard  manual  labor. 

Past  History. — Ten  years  ago  had  malaria.  After  at- 
tacks of  chills  and  fever,  did  not  menstruate  for  6  months. 
Five  years  ago  had  attack  of  dysentery  which  lasted  6 
weeks. 

Present  Trouble. — Five  months  ago  the  patient  for  the 
first  time  in  her  life  began  to  have  trouble  with  her  stomach. 
Noted  gassy  eructations  and  pjo-osis,  together  with  burning, 
epigastric  pain  coming  on  soon  after  eating.  Was  never 
quite  free  from  epigastric  pain.  For  past  3  months  has 
had  attacks  of  diarrhea  coming  on  every  2  or  3  weeks.  Two 
months  ago  began  to  feel  nauseated  in  the  middle  of  the 
afternoon;  6  weeks  ago  began  to  vomit  every  day  in  late 
afternoon;  vomiting  resulted  from  epigastric  pain  and 
bloating.  Never  vomited  blood,  but  frequently  vomited 
material  eaten  for  breakfast. 

Appetite. — Poor. 

Boivels. — Rather  diarrheic;  never  dark  colored. 

Weight. — Has  lost  22  pounds  in  about  3  months,  and  feels 
much  weaker  than  fonnerly. 

Physical  Examination. — Anemic,  poorly  nourished,  com- 
plexion sallow,  slight  peripheral  edema,  looks  tired;  tongue, 
coated;  teeth,  dirty. 

Chest. — Negative  except  for  slight  muscular  weakness  of 
heart. 


140  CANCER  OF  THE  STOMACH 

Abdomen. — A  hard,  nodular,  movable  mass,  size  of  adult 
fist  in  mid-epigastrium;  is  somewhat  tender  to  the  touch. 
No  gland  enlargements  palpable. 

Pelvic  Examination. — Negative. 
Laboratory  Examinations: 

Blood.— Kg.,  70  per  cent.;  r.b.c,  4,000,000;  w.b.c,  6,200. 

Test-meal. — Total  acidity,  74;  free  Hcl,  6;  combined 
acids,  58;  lactic  acid-|-;  altered  blood  +  (guaiac  test).  Re- 
tention moderate. 

Microscopical  Examination. — Occasional  long  bacillus 
of  Oppler-Boas  type;  few  leptothrix  and  short  fat  rods. 

Laparotomy. — High  right-rectus  incision;  mass  the  size 
of  grape  fruit  on  lesser  curvature  near  pyloric  end.  Tumor 
circumscribed.     Shght  gland  enlargement. 

Operation. — Mikulicz-Hartman,  Billroth  No.  2.  Posterior 
gastroenterostomy. 

Pathologic  Report. — Adenocarcinoma. 

3.  Alcoholism;  Chronic  Gastritis;  Umbilical  Metastasis: 

Mr.  C.  F. — Age  46,  American,  merchant. 

Family  History. — Negative. 

Personal  History. — Typhoid  fever  9  years  ago,  very  ill, 
since  then  has  had  scarlet  fever,  measles  and  whooping 
cough;  denies  venereal  disease.  Was  a  hard  drinker  up  to 
a  year  and  a  half  ago,  since  then  temperate. 

Present  Illness. — Gastric  disturbance  1  year,  previous  to 
that  says  he  not  infrequently  had  indigestion,  especially 
following  drinking  bouts. 

Complaint. — Dull  aching  pain,  moderately  constant  in 
epigastrium;  reaches  its  maximum  about  3  hours  after 
meals.  Has  found  nothing  that  would  relieve  pain  except 
rest  and  vomiting. 

Nausea,  prominent  symptom,  comes  on  after  every  meal 
and  is  followed  by  vomiting.  Vomits  large  amounts  of 
finely  divided  food,  whitish  in  color  and  sour  to  taste. 
Sometimes  delayed  vomitus.     Never  vomited  blood. 

Belching  almost  constantly  with  much  regurgitation  of 
food,  even  on  liquid  diet. 

Bowels. — Constipated;  never  blood  or  dark  stools. 

Weight  Loss. — Seventy  pounds  in  8  months. 

Physical  Examination. — Moderately  well  developed,  but 
poorly  nourished;  color  rather  florid.     Tongue  coated. 


SYMPTOMATOLOGY  141 

Head,  Neck  and  Chest. — Negative. 

Abdomen. — Scaphoid,  no  tenderness  on  deep  pressure  in 
any  part.     On  inspiration,  a  hard,  irregular  mass  is  felt 
high  in  the  epigastrium  to  right  of  median  line.     Is  about 
4  inches  long  and  not  tender. 
Laboratory  Examinations: 

Blood.- — Hg.,  60  per  cent. 

Test-meal. — Tube  meets  slight  resistance  at  cardia  with 
rather  free  bleeding.  Small  amount  of  retained  food. 
Total  acidity,  16;  free  Hcl,  0;  combined  acids,  10;  lactic 
acid,  trace;  Wolff- Junghans'  test  for  soluble  albumin  +  (300 
units);  altered  blood  +  (benzidin  test). 

Microscopic  Examination. — Oppler-Boas  bacilli;  few  bud- 
ding yeasts;  streptococci  and  short,  fat  rods  in  chains. 

Stool. — Altered  blood  +  (benzidin  test). 

Laparotomy. — Stomach  is  involved  in  one  mass  of  cancer, 
adherent  to  transverse  colon  and  jejenum.  There  is  a 
maUgnant  metastasis  to  umbilicus. 

Operation. — Exploratory. 

Pathologic  Report. — Perigastric  gland  shows  cancer  cells. 

4.  Slow  Onset  with  Vomiting  a  Prominent  Symptom.  Abdom- 
inal Tumor  Noted  for  8  Months: 

Mrs.  A.  D. — Age  46,  American,  housewife. 

Family  History. — One  sister  died  of  "  quick  consumption." 

Personal  History. — Pleurisy  5  years  ago,  lumbago  for 
many  years,  otherwise  well. 

Present  Illness. — ''Indigestion"  for  past  23^  years;  this 
has  been  characterized  by  pain  in  mid-epigastrium  con- 
stantly present  and  of  gnawing  character ;  pain  transmitted 
to  back  between  shoulders.  Pain  has  been  constant  and 
not  relieved  by  diet,  medicine  or  posture. 

Nausea.- — A  marked  symptom,  prostrating  and  comes 
any  time  of  day  or  night ;  worse  when  lying  down. 

Vomiting. — For  the  past  month  vomiting  after  every 
meal;  vomitus  contains  food  but  no  blood;  never  bad 
taste;  vomitus  watery,  never  colored;  relieves  some  of 
the  distress;  been  on  liquid  diet  but  no  relief. 

Belches  gas  constantly;  never  sour;  no  relief  by  soda. 

Constipation. — Marked;  never  blood. 

Flatulence. — Marked. 


142  CANCER  OF  THE  STOMACH 

Weight  Loss. — Twenty-four  pounds  in  2  years. 

Genito-urinary. — No  urinary  symptoms.  Menopause 
1  year  ago. 

Physical  Examination. — Fairly  well  developed  and  nour- 
ished ;  moderate  pallor. 

Tongue. — Slightly  coated. 

Head,  Neck  and  Chest. — Negative. 

Abdomen. — Diastasis  of  recti  muscles  with  dilatation  of 
superficial  cutaneous  veins.  Just  above  navel  is  a  semi- 
lunar, freely  movable  mass  12  cm.  long  and  5  cm.  wide,  not 
tender;  can  be  displaced  up  and  down  but  not  freely  from 
side  to  side.     Tenderness  over  gall-bladder. 

Vaginal. — Perineum  lacerated. 
Laboratory  Examinations: 

Blood.— Rg.,  70  per  cent.;  r.b.c,  4,200,000;  w.b.c, 
7,800. 

Test-meal. — Resistance  to  tube  at  cardia;  no  bleeding. 
Slight  12-hour  retention.  Total  acidity,  24;  free  Hcl,  2; 
combined  acids,  18;  lactic  acidH-;  altered  blood  +  (guaiac 
test);  Wolff-Junghans'  test  for  soluble  albumin-}-  (more 
than  200  units) .  Glycyltryptophan  test  -1- ;  f ormol  index, 
22  (Sorenson-Schiff  method). 

Microscopic  Examination. — Few  bacilli  of  Oppler-Boas 
type. 

Stool. — Altered  blood  +  (benzidin  test). 

Laparotomy. — Pylorus  and  entire  lesser  curvature  car- 
cinomatous; stomach  thickened,  small  (leather  bottle  type). 

Operation. — Explored. 

Pathologic  Report. — Gland  shows  carcinoma. 

5.  Rapid  Onset  and  Few  Symptoms.     Cancer  in  Family: 

Mrs.  E.  S. — Age  79,  German,  housewife. 

Family  History. — One  sister  dead,  cancer  of  the  stomach; 
1  daughter  dead,  cancer  of  the  rectum. 

Personal  History. — Past  negative. 

Present  Ulness. — Vague  gastric  disturbance  for  4  months. 

Complaint. — Heavy  feeling  in  abdomen  immediately 
after  eating;  lasts  1  to  2  hours. 

Distress  Relief. — When  bowels  move  or  when  belches. 
Few  eructations,  no  nausea  or  vomiting  at  any  time. 

Bowels. — Constipated,  never  melena. 


SYMPTOMATOLOGY  143 

Appetite. — Fair. 

Physical  Examination. — Well  developed  and  moderately 
well  nourished.     Rather  pale. 

Tongue. — Clean. 

Head  and  Neck. — Negative. 

Chest. — Heart;  slight  arrhythmia. 

Lungs. — Negative. 

Abdomen. — Small   hard   movable   mass    1    cm.    to   left 
and  2  cm.  above  navel.    Mass  painful  on  pressure.    Exami- 
nation otherwise  negative. 
Laboratory  Examinations: 

Blood— B.g.,  50  per  cent.;  r.b.c,  2,800,000;  w.b.c, 
12,000. 

Test-meal. — Moderate  12-hour  retention.  Total  acidity, 
46;  free  Hcl,  8;  combined  acids,  22;  lactic  acid,  trace; 
altered  blood  +  (guaiac  test) ;  Wolff -Junghans'  test  -f-  (300 
units) . 

Microscopic  Examination. — Oppler-Boas  bacilli,  many 
cocci  and  small  type  sarcinse. 

Laparotomy. — Carcinoma  of  pylorus  and  antrum  extend- 
ing to  first  part  of  duodenum.     Roux  operation. 

Pathologic  Report. — Adenocarcinoma. 

6.  Acute  Onset,  Severe  Pain  a  Prominent  Symptom;  Carci- 
noma Involving  Pylorus;  Gall-stones: 

Mr.  C.  L. — Age  68,  American,  engineer. 

Family  History. — Negative. 

Personal  History. — Usual  diseases  of  childhood;  had 
pneumonia  3  times,  40,  14  and  7  years  ago;  had  typhoid 
fever  35  years  ago.  Claims  to  have  had  3  attacks  of 
appendicitis,  one  53  years  ago,  one  56  years  ago  and  one 
6  years  ago;  in  bed  each  time  for  from  5  days  to  2  weeks. 
Had  7  attacks  of  severe  la  grippe.  Denies  venereal 
disease. 

Present  History. — Three  months  ago  was  taken  with 
severe  cramp  in  lower  abdomen,  immediately  after  eating; 
it  lasted  15  minutes.  Twelve  hours  later  again  very 
severe  cramp  with  nausea.  No  chills,  fever,  sweats  or 
jaundice.  Since  then  patient  has  constantly  had  hard 
epigastric  ache  with  nausea,  water-brash  and  eructations. 
Vomits  immediately  after  eating  and  frequently  vomitus 


144  CANCER  OF  THE  STOMACH 

contains  food  eaten  24  to  48  hours  previously.     Never 
vomited  blood  or  noted  dark  stools. 

Appetite. — Fair. 

Bowels. — Constipated. 

Weight  Loss. — Twenty  pounds  in  2  months. 

Physical  Examination. — Emaciated,  anemic.  Skin  dry 
and  scaly;  post-malleolar  edema;  no  adenopathy. 

Eye  Reaction. — Normal.     Eye  grounds  negative. 

Tongue. — Coated. 

Thorax. — Apices  rather  dull  to  percussion. 

Heart. — Slightly  enlarged;  second  aortic  tone  roughened. 
Moderate  arteriosclerosis. 

Abdomen. — Visible  peristaltic  waves  running  from  left  to 
right  in  region  of  navel. 

Stomach. — By  percussion  reaches  almost  to  symphysis. 
No  tumor  palpable.     Resistance  in  right  upper  quadrant 
to  deep  palpation. 
Laboratory  Examinations: 

Urine. — Trace  of  albumin. 

Blood.— Rg.,  40  per  cent.;  r.b.c,  3,060,000;  w.b.c,  9,000. 

Test-meal. — Marked  12-hour  retention.  Total  acidity, 
84;  free  Hcl,  12;  combined  acid,  38;  lactic  acid  +  ;  altered 
blood  +  (benzidin  test). 

Microscopic  Examination. — Great  numbers  of  Oppler- 
Boas  bacilU;  colonies  of  yeasts. 

Stool. — Altered  blood  +  (benzidin  test). 

Laparotomy . — High  right-rectus  incision.  Gall-bladder 
6  times  normal  size.  Adherent  to  omentum  and  contains 
several  large  stones.  Stomach  dilated.  Carcinoma  in- 
vohdng  pylorus  and  antrum  with  marked  stenosis.  Ap- 
pendix adherent  to  anterior  abdominal  wall.  Glands 
along  lesser  curvature  carcinomatous. 

Operation. — Posterior  gastroenterostomy;  separation  of 
gall-bladder  adhesions;  appendicectomy,  cholecystostomy. 

Pathologic  Report. — Gland :  carcinoma. 

7.  Acute   Onset  with  Pain  and  Vague  Dyspepsia;  Rapid 
Weight  Loss;  Gastric  Carcinosis: 
Mr.  W.  B. — Age  62,  German,  miller. 
Family  History. — Negative. 
Personal  History. — Patient   was   never  sick  in  his  life 


SYMPTOMATOLOGY  145 

until  6  weeks  ago.  Unaccountabl}^,  he  began  to  lose 
appetite  and  to  experience  pain  from  the  epigastrium  into 
the  left  flank.  This  pain  was  best  described  as  a  "pulling 
sensation;"  a  week  later  began  to  have  soreness  in  the  right 
hypochondrium,  was  never  severe,  but  has  been  fairly- 
constant.  Five  weeks  ago  troubled  with  bitter  eructations 
and  water-brash  1  hour  after  eating;  never  vomited; 
appetite  has  been  rather  poor;  hea^^  meals  aggravate  the 
p^Tosis. 

Bowels. — Constipated. 

Strength. — Poor;  tires  easily. 

Weight. — Has  lost  40  pounds  in  less  than  5  weeks. 

Physical  Examination. — Patient  poorly  nourished;  an- 
emic; mucous  membranes  pale;  tongue  coated;  teeth  poor; 
chest,  negative. 

Ahdomen. — Marked  peristaltic  waves  extending  across  the 
epigastrium  to  the  right  of  the  umbiUcus.     No  tumor  mass 
palpable.     No  abdominal  tenderness. 
Laboratory  Examinations : 

Blood.— Kg.,  30  per  cent.;r.b.c.,  2,400,000;  w.b.c,  13,500. 

Test-meal. — Bleeding  as  tube  passes  cardia.  Alarked 
12-hour  retention.  Total  acidity,  32;  free  Hcl,  0;  com- 
bined acids,  22;  lactic  acid,  trace;  altered  blood  +  (guaiac 
test). 

Microscopic  Examination. — Numerous  bacilh  of  the 
Oppler-Boas  tjqje. 

Stool. — Altered  blood  +  (guaiac  test). 

Laparotomy . — High  median  incision.  Carcinoma  in- 
volving the  entire  stomach  except  cardiac  end.  Appeared 
to  be  primary  on  posterior  wall.  Gall-bladder  filled  vAih. 
stones  (261).     Extensive  gland  involvement. 

Operation. —  Gastrectomy,  four-fifths  of  stomach  re- 
moved; gastro-enterostomy;  cholecystostomy. 

Pathologic  Report. — Adenocarcinoma. 

8.    Early  Hemorrhage;  Pain  and  Vomiting: 

Mr.  J.  S. — xlge  65,  Swedish,  laborer. 

Family  and  Personal  History. — Negative. 

Comes  for  epigastric  pain  and  vomiting  of  food  and  blood. 

Present  Illness. — Three  months  ago  moderately  acute 
pain  in  high  epigastrium.  Pain  now  comes  on  at  once  after 
eating;  lasts  3  to  4  hours.     Pain  reUeved  only  by  vomiting. 

10 


146  CANCER  OF  THE  STOMACH 

Vomiting  follows  every  meal;  greater  in  amount  after 
heavy  meal.  Almost  daily  vomits  bright  bloody  fluid.  Is 
constantly  nauseated. 

Appetite. — Poor;  lives  on  milk  and  eggs. 

Bowels. — Constipated  25  years. 

Urinary  System. — Negative  except  for  peculiar  odor  of 
urine. 

Weight  Loss. — Thirty  pounds  in  3  months.     Is  very  weak. 

Physical  Examination. — Well  developed  and  well  nour- 
ished, color  fair,  tongue  and  sclera  negative. 

Head,  Neck  and  Chest. — Negative. 

Abdomen. — Slight,  deep  tenderness  in  pit  of  stomach, 
negative  otherwise. 
Laboratory  Examinations: 

5Zood—Hg.,  60  per  cent.;  r.b.c,  4,000,000;  w.b.c,  11,000. 

Test-meal. — Dark  brown  liquid  with  small  amount  of 
retained  food.  Total  acidity,  15;  free  Hcl,  10;  combined 
acids,  4;  lactic  acid,  0;  altered  +  blood  (benzidin  test); 
Wolff-Junghans'  test+  (300  units  of  precipitable  albumin). 

Microscopic  Examination. — Many  short  rods;  few  bud- 
ding yeasts. 

Stool. — Altered  blood  +  (benzidin  test). 

Laparotomy. — Ulcus  carcinomatosum,  anterior  wall  near 
pylorus. 

Operation. — Pylorectomy,  posterior  gastroenterostomy. 

Pathologic  Report. — Adenocarcinoma. 

(6)  Symptomatology  when  the  Cancer  is  Well  Established. 

— Perusal  of  the  foregoing  histories  demonstrates  that  cer- 
tain symptoms  are  fairly  common  after  the  neoplasm  has 
advanced  beyond  its  incipient  stage.  Factors  which 
modify  clinical  manifestations  are  the  histologic  type  of 
growth,  the  location  of  the  neoplasm,  ulceration,  perfora- 
tion, the  degree  of  involvement. 

Delayed  vomiting  was  a  sign  in  211  (54  per  cent.)  of  all  the 
cases  where  emesis  occurred.  Such  vomiting  was  most  com- 
monly due  to  pyloric  stenosis,  malignant  ''hour-glass,"  [or 
obstruction  at  the  cardia,  with  dilatation  of  the  esophagus. 

Appetite  was  ''poor"  in  353  instances   (81  per  cent.). 


SYMPTOMATOLOGY  147 

It  was  ''fair"  in  70  cases  (16  per  cent.).  In  but  13  patients 
(2.9  per  cent.)  was  appetite  recorded  ''good"  when  the 
period  of  mahgnancy  had  come  on. 

Dysphagia  was  noted  in  8  cases  of  this  group  (1.8  per 
cent.).  When  such  was  present  the  neoplasm  involved  the 
cardia,  the  high  lesser  curvature  or  the  fundus. 

Hemorrhage. — Of  the  whole  number  bleeding  in  this  group 
(92  cases),  21  instances  (22.9  per  cent.)  of  hemorrhage  oc- 
curred within  1  year  of  the  patient's  coming  under  observa- 
tion. Hematemesis  was  noted  in  17  and  melena  in  4 
cases. 

^'Occult"  Hemorrhage. — Tests  for  the  demonstration  of 
altered  blood  in  the  feces  were  positive  in  86  per  cent,  of 
cases  in  this  group  where  the  reaction  was  sought  {vide 
Chapter  V). 

Temperature. — It  has  been  stated  that  approximately 
one-third  of  gastric  cancer  patients  have  elevations  in 
temperature  during  some  portion  of  the  malignant  ailment 
(Fenwick).  Ulceration,  extensive  metastases,  perforation, 
sepsis  of  the  cancer  locally,  or  a  systemic  subinfection  are 
considered  causes  of  the  increase.  It  is  quite  likely  that 
the  absorption  of  cancer  proteid  or  products  of  its  digestion 
may  cause  fever.  Various  observers,  particularly  Vaughan, 
have  emphasized  the  fact  that  parenteral  digestion  of 
proteid  by  ferments  in  blood  or  body  fluids  may  cause 
hyperpyrexia.  It  would  seem  that  the  presence  of  cancer 
proteid  in  the  blood  or  lymphatic  circulation,  in  the  form  of 
metastasizing  cells,  Hving  or  dead,  or  the  products  of  their 
digestion  by  ferment  activity,  might  account  for  fever, 
continuous  or  intermittent^  in  gastric  cancer. 

Of  our  cases,  there  were  79  instances  where  temperature 
records  had  been  kept.  In  12  cases  (1.51  per  cent.) 
temperatures  above  99°  F.   were  recorded.     The  lowest 


148  CANCER  OF  THE  STOMACH 

was  99.2°  F.  (a  case  of  fungoid  cancer  involving  the  pars 
media);  the  maximum  was  102.6°  F.  (an  instance  of  ful- 
minant gastric  carcinosis  with  extensive  metastases). 
The  average  temperature  of  this  group  was  100.4°  F. 

Weight  Loss. — Definite  information  was  possible  in  197 
cases  in  this  group.  Detailed  information  is  given  in 
Chapter  IV.  The  minimum  weight  loss  was  11  pounds; 
the  maximum  72  pounds,  and  the  average  22.7  pounds. 
Rapid  decrease  in  weight  was  commonlj^  noted  when 
stenoses  of  the  orifices  of  the  stomach  brought  on  obstinate 
vomiting,  or  where  marked  anorexia  or  pain  on  food  in- 
gestion Hmited  nourishment. 

Urine. — One  cannot  always  attribute  changes  in  urine 
analysis  to  the  nature  of  the  disease.  It  must  be  re- 
membered that  the  majority  of  cancer  patients  are  past  the 
fourth  decade,  i.e.,  at  a  time  when  faulty  kidney  functioning 
is  by  no  means  uncommon.  In  febrile  cases,  one  expects 
to  find  albumin  and  casts  in  the  urine,  as  happens  similarly 
in  febrile  benign  affections.  Indican,  urea,  total  nitrogen, 
and  sulphates  are  said  to  be  increased.  Total  24-hour 
quantity  and  chlorides  may  be  considerably  below  normal. 
We  have  definite  information  respecting  the  urine  in  pa- 
tients making  up  this  group,  available  in  141  cases.  In  81 
cases  (57  per  cent.)  the  24-hour  quantity  of  urine  was 
1,000  cc.  or  below.  In  13  instances  (9.2  per  cent.)  casts 
were  noted.  In  21  cases  (14.9  per  cent.)  albumin  was 
present  alone  or  associated  with  casts. 

Duration  of  the  Disease. — Approximately  6  out  of  10  cases 
were  dead  within  1  year  following  theh  coming  under 
observation.  Xot  quite  2  out  of  10  lived  longer  than  3 
years  and  but  rather  more  than  1  out  of  7  patients  were 
ahve  at  the  end  of  5  years  even  when  the  most  radical 
surgical  procedures  were  carried  out. 


SYMPTOMATOLOGY  149 

Group  rv.  Gastric  Cancer  in  Individuals  in  Whom  Malignancy  followed 
Periods  of  Gastric  Disturbance  of  Irregular  Clinical  Type 

There  were  84  cases  (9.12  per  cent.)  in  this  group.  There 
were  38  males  and  46  females.  The  average  period  of 
gastric  disturbance  preceding  the  evidently  malignant 
disease  was  9.1  years. 

As  in  cases  making  up  Group  II,  there  were  two  definitely 
separate  types  of  dyspepsia  in  these  patients,  namely,  the 
first,  an  indigestion  of  the  cHnicaUy  benign  type,  and  second, 
a  supervening  gastric  disturbance,  easily  recognized  as 
mahgnant.  The  mahgnant  stage  of  the  disease  averaged 
6.2  months. 

(a)  The  Precarcinomatous  Stage  of  Dyspepsia. — During 
an  average  period  of  more  than  9  years,  patients  in  this 
group  have  been  affected  with,  digestive  disturbances  sug- 
gestive of  gastritis,  cholecystitis,  cholelithiasis,  chronic 
appendicitis,  pancreatitis  or  dyspepsia  seemingly  of  func- 
tional foundation.  But  rarely  did  histories  present  a  clean- 
cut  symptomatology.  The  dyspepsia  was  continuous  in 
type  in  12  cases.  Questionable  hemorrhage  had  been  noted 
in  7  instances  (8.3  per  cent.). 

Vomiting,  usuaUy  intermittent,  occurred  in  30  cases 
(36  per  cent.). 

Abdominal  pain  was  complained  of  by  70  patients  (83 
per  cent.).  Severe  colicky  attacks  were  recorded  8  times 
(9.5  per  cent.). 

Jaundice  had  occurred  in  5  patients. 

Gall-stones  had  been  removed  in  3  instances.  They  were 
demonstrated  at  the  laparotomy  for  the  malignant  affection 
in  4  other  cases. 

Water-brash,  eructations  and  pjTosis  occupied  a  promi- 
nent place  in  the  symptomatology  of  the  affection  at  this 
stage.     They  had  not  infrequently  formed  a  basis  for  the 


150  CANCER  OF  THE  STOMACH 

early  diagnosis  of  ''hyperacidity  with  probable  gastric 
ulcer,"  but  had  not  been  associated  with  other  clinical 
evidences  of  such  disease. 

Weight  loss  had  averaged  13.1  pounds  in  77  cases,  where 
definite  data  were  recorded.  Anemia  and  cachexia  had 
been  rare,  except  in  several  of  the  nervous  patients. 

Appetite  was  usually  good,  except  in  the  ''spells"  of 
more  or  less  pronounced  dyspepsia. 

Constipation  was  noted  in  51  cases  (63  per  cent.),  diar- 
rhea was  observed  4  times. 

(b)  The  Carcinomatous  Period. — Its  onset  was  rarely 
acute.  In  2  cases  severe  hematemesis  ushered  in  the  stage 
of  malignancy.  In  the  majority  of  cases  weight-loss, 
weakness,  anemia,  anorexia,  continuous  dyspepsia,  ab- 
dominal discomfort,  vomiting  and  epigastric  tumor  came 
on  gradually.  The  course  of  this  period  of  the  ailment  was 
in  every  way  similar  to  that  forming  the  second  part  of 
cases  in  Group  II  or  to  the  whole  course  of  cases  making 
up  Group  III.  Only  the  history  of  the  early  years  of  the 
dyspepsia  identified  the  group. 

The  following  cases  are  representative  of  this  class: 

1.  Gastric  Malignancy  Following  12  Years  of  Irregular  Dys- 
pepsia— Ulcer  (?),  Gall-Bladder  (?): 

Mrs.  A.  V. — Age  68,  American,  housewife. 

Family  History. — Negative. 

Personal  History. — When  young  had  scarlet  fever,  diph- 
theria, pneumonia.     Ovariotomy  6  years  ago. 

Present  Trouble. — Up  to  6  months  ago  had  for  12  years 
irregular  attacks  of  indigestion.  These  were  character- 
ized by  abdominal  pain  soon  after  eating,  flatulence  and 
occasional  vomiting  of  green,  watery  fluid.  In  the  attacks 
constipation  was  marked.  Attacks  lasted  from  2  to  4 
weeks.  Abdominal  discomfort  was  relieved  by  vomiting 
diet  and  food  ingestion  (?). 

Six  months  ago  began  to  notice  gradual  loss  in  weight 


SYMPTOMATOLOGY  151 

and  gastric  distress  became  more  or  less  continuous. 
Vomiting  came  on  daily  soon  after  eating,  and  nausea, 
eructations  and  pyrosis  were  constant. 

Appetite. — Poor. 

Bowels. — Constipated. 

Weight. — ^Lost  40  pounds  in  4  months. 

Examination. — Small,  pale,  poorly  nourished  female. 

Head,  Neck  and  Chest. — Negative. 

Abdomen. — Tender  to  pressure  throughout  epigastrium; 
suggestion  of  a  high  transverse  ridge  just  below  the  ensi- 
form. 

Rectal  Examination. — Negative. 
Laboratory  Examinations: 

Blood. — Hg.,  84  per  cent.;  r.b.c,  4,480,000;  w.b.c, 
17,500. 

Test-meal. — No  12-hour  retention.  Total  acidity,  4; 
free  Hcl,  0;  altered  blood +;  lactic  acid  (?);  Wolff  test-j-. 

iS^ooL— Altered  blood  (?). 

X-ray. — Filling  defect  on  the  lesser  curvature  near  the 
cardia;  malignant  hour-glass. 

Laparotomy. — High  median  incision,  irremovable  tumor 
of  the  body  of  the  lesser  curvature  of  the  stomach;  exten- 
sive perigastric  gland  involvement. 

Pathologic  Report. — Gland  removed  showed  carcinoma. 

2.  Irregular  Previous  Gastric  History — Ulcer  {?),  Pancreati- 
tis (?),  Cholecystitis  (?) — with  Supervening  Malignancy: 

Mr.  E.  H.  A. — Age  57,  Hebrew,  salesman. 

Family  History. — Negative. 

Personal  History. — Negative,  denies  venereal. 

Duration  of  Present  Illness. — For  the  past  20  years  has 
suffered  from  epigastric  pain  associated  with  severe  diar- 
rhea. Until  10  months  ago  this  trouble  occurred  in  spells. 
Pain  was  usually  in  the  right  epigastrium  and  was  most 
marked  2  hours  after  eating.  It  would  be  relieved  by 
vomiting,  alkalies,  diet  or  the  belching  of  gas.  The 
diarrhea  was  watery  in  type  and  frequently  contained 
undigested  food.     Never  passed  blood. 

Ten  years  ago  began  to  have  constant  diarrhea  and 
epigastric  distress  associated  with  loss  of  weight  and 
strength.     Appetite  became  poor  and  anemia  developed. 


152  CA^XER    OF    THE    STOMACH 

Bowels. — Four  to  6  movements  a  day;  watery  and  mth- 
out  pain. 

Weight. — Sixty  pounds  loss  in  a  year. 

Examination. — Sallow,  anemic  male. 

Throat,  Neck  and  Thorax. — Negative. 

Abdomen. — Scaphoid  in  shape;  movable  mass  in  the 
right  upper  quadi'ant  from  the  mid-hne  to  the  rib  edge. 

Rectal. — Xegat  i  ve . 

Lahoratory  Examinations. — Hg.,  32  per  cent.;  r.b.c, 
4,000.000;  w.b.c,  5,000.  Small  hTnphocytes  25.3  per  cent.; 
large  hnnphocytes,  8.7;  pohmuclears,  60.7;  transitionals,  1; 
eosinophiles,  2.6;  basophiles,  1.7. 

Test-meal. — Xo  retention.  Total  acidity,  9;  free  Hcl,  0; 
lactic  acid+;  altered  blood +  . 

Stool. — Altered  blood+. 

Laparotomy . — High  right  rectus  incision.  Cancer  the 
size  of  a  cocoanut,  invohing  the  stomach;  metastases  to 
the  Uver  and  abdominal  lymphatics. 

Pathologic  Report. — Gland  showed  carcinoma. 

3.  Previous  Dyspepsia,  Ulcer  Type;  Large  Supraclavicular 
Fossa  Metastasis;  Few  Recent  Gastric  Symptoms: 

Mr.  E.  K.  B.^ — Age  61,  American,  travehng  salesman. 

Family  History. — Negative. 

Personal  History. — Uses  tobacco  and  alcohol  in  modera- 
tion. 

Duration  of  Present  Trouble. — Up  to  5  years  ago  had 
dyspeptic  attacks  characteristic  of  gastric  ulcer.  Epigas- 
tric pain  2  to  5  hom-s  after  eating  which  was  relieved  by 
food  intake,  alkalies  or  whiskey;  these  attacks  occm'red  in 
spells  several  times  a  year;  2  hemorrhages  from  the  stomach 
30  years  ago;  moderate  constipation. 

These  attacks  continued  until  about  5  j-ears  ago  when 
dyspepsia  disappeared.  Patient  felt  well  until  6  months 
ago  when  he  began  to  feel  vague  abdominal  distress  soon 
after  eating,  experienced  nausea,  began  to  lose  weight  and 
noted  a  gi'adually  enlarging  tumor  above  the  left  clavicle. 
This  tumor  was  examined  4  days  pre^^ous  to  his  coming 
under  our  observation  and  pronounced  Hodgkin's  disease. 
Under  .T-ray  treatment  this  tumor  became  smaller  but  is 
again  rapidly  enlarging. 


SYMPTOMATOLOGY  153 

Appetite. — Poor. 

Bowels. — Slightly  constipated. 

Weight. — One  year  ago  200  pounds;  6  months  ago  190; 
present,  157. 
Examination: 

Throat. — Hypertrophied  adenoid  tissue. 

Neck. — Firm,  nodular,  tender  tumor  size  of  small  grape 
fruit  in  left  supraclavicular  space.  Tumor  is  fixed  and 
below  it  are  several  smaller  nodules.  In  left  axilla  lymph 
gland  size  of  a  walnut. 

Thorax. — Negative. 

Abdomen. — Rounded;  tenderness  on  deep  pressure 
over  right  and  mid-epigastrium.  Dulness  on  percussion. 
Greater  curvature  of  stomach  1  f.b.  below  navel. 

Rectal  Examination. — Negative. 
Laboratory  Examinations: 

Blood.— Hg.,  50  per  cent.;  r.b.c,  3,600,000;  w.b.c, 
13,200. 

Test-meal. — Stomach  tube  meets  resistance  at  cardia 
with  free  bleeding.  Total  acid,  62;  free  Hcl,  38;  altered 
blood +  ;  lactic  acid,  0;  Wolff +  . 

Microscopic  Examination. — Yeasts;  sarcinse;  many  diplo- 
cocci  and  short  fat  bacilli. 

Stool. — Altered  blood +  . 

X-ray  Examination. — Filling  defect,  involving  pars  py- 
lorica;  moderate  gastric  retention. 

Operation. — Block  dissection  of  neck  tumor  showed  sec- 
ondary carcinomatous  metastasis  from  the  stomach. 

Pathologic  Report. — Carcinoma. 

Group   V.    Gastric   Cancer  in  Individuals   Who  Presented  Few  Clinical 
Evidences  of  a  Malignant  Process  Primary  in  the  Stomach  "Wall 

Such  cases  numbered  19,  or  2.1  per  cent,  of  our  entire 
series.  This  class  of  case  is  extremely  difficult  to  recog- 
nize clinically.  The  symptoms  are  very  vague.  Unless 
tumor  appears  the  clinical  picture  is  apt  to  be  that  of 
*' nervous"  dyspepsia,  arteriosclerosis,  pernicious  anemia, 
Bright's  disease,  Addison's  disease,  chronic  gastritis, 
achylia  gastrica,  colitis,  tabes  or  extragastric  neoplasm. 


154  CANCER  OF  THE  STOMACH 

In  our  series  there  were,  however,  certain  ear-marks  of 
maUgnancy  even  though  such  did  not  appear  to  primarily 
involve  the  stomach.  All  the  patients  had  lost  weight. 
The  average  loss  was  18.2  pounds. 

Anemia  was  never  pronounced.  In  only  1  case  was 
hemoglobin  below  50  per  cent,  and  red  cell  count  lower  than 
3,000,000  cells.     The  color  index  averaged  0.72. 

Abdominal  tumor  was  palpable  in  5  cases.  Its  common 
situation  was  to  the  left  of  the  mid-line. 

Diarrhea  was  a  symptom  in  7  cases  (43.7  per  cent.). 

Blood  was  noted  in  the  stools  twice.  Abdominal  dis- 
tress was  complained  of  in  but  3  cases.  In  but  1  instance 
was  it  severe.  Vague  ''uneasy"  sensations  were  not  un- 
common. Unaccountable  nausea  or  anorexia,  sudden  belch- 
ing of  gas  or  the  regurgitation  of  bitter,  salt,  or  ''rotten" 
fluid  not  rarely  led  to  the  visit  to  a  physician.  Dizziness, 
mental  confusion,  shortness  of  breath  or  profuse  per- 
spiration on  even  moderate  exertion  were  not  uncommon 
complaints.  Signs  of  mental  depression,  almost  of  mel- 
ancholic grade,  developed  in  1  patient.  Laparotomy,  test- 
meal  analyses  or  Roentgen  examination  usually  rendered 
positive  a  diagnosis  previously  but  suspicious  for  malignant 
disease  of  the  stomach. 

Some  of  the  peculiarities  of  this  group  are  emphasized  in 
the  histories  below. 

1.  Rapid  Onset,  Few  Symptoms,  Irremovable  Carcinoma  of 
the  Greater  Curvature: 

Mrs.  I.  M. — Age  50,  Swedish,  housewife. 

Family  History. — Negative. 

Personal  History. — For  the  past  6  weeks  has  had  a  bloated 
sensation  in  abdomen  a  few  hours  after  meals.  No  belch- 
ing, eructations,  or  vomiting;  no  nausea.  For  the  past  2 
weeks  has  had  soreness  in  epigastrium  and  the  left  lumbar 
region  almost  continuously,  and  a  week  ago  discovered  an 
epigastric  "lump." 


SYMPTOMATOLOGY  155 

Appetite. — Fair. 

Bowels. — Diarrheic  during  the  last  3  weeks. 

Weight  Loss. — Twenty  pounds  in  1  month. 

Physical  Examination. — Well  developed,  but  poorly 
nourished;  mucosae  anemic,  tongue  shghtly  coated;  chest 
negative. 

Abdomen. — At  the  left  costal  margin  a  mass  the  size  of  a 
hen's  egg;  it  is  hard  and  tender  and  moves  downward  on 
respiration.     Abdomen  otherv^dse  negative. 
Laboratory  Examinations: 

Blood.— Rg.,  70  per  cent.;  r.b.c,  3,600,000;  w.b.c, 
11,600. 

Test-meal. — SUght  12-hour  retention.  Gastric  contents 
blood  stained;  total  acidity,  14;  free  Hcl,  0;  lactic  acid  +; 
altered  blood +  ;  Wolff  test  +  . 

Stool. — Altered  blood. 

Roentgen  Examination. — FiUing  defect  in  pars  media  of 
greater  curvature;  malignant  hour-glass;  peristalsis  absent; 
pylorus  gaping;  stomach  j&xed. 

Laparotomy. — High  right  rectus  incision;  tumor  mass 
involves  whole  of  greater  curvature;  extensive  gland  in- 
volvement. 

Operation. — Explored. 

Pathology. — Gland  showed  carcinoma. 

2.  Primary  Carcinoma  of  Pyloric  End  of  Stomach;  Few 
Symptoms: 

Mr.  A.  S. — Age  49,  Hebrew,  tailor. 

Family  History. — Had  '^ quinsy"  as  a  boy.  Denies 
venereal  disease. 

Present  Trouble. — Has  been  constipated  for  2  years. 
Four  weeks  ago,  while  bathing,  noticed  tumor  size  of  a 
lemon  in  left  abdomen.  Since  then  has  had  sensation  of 
tightness  and  pressure  in  the  epigastrium;  usually  most 
severe  1  to  2  hours  p.c.  Belches  gas  occasionally.  Thinks 
strength  is  somewhat  diminished. 

Appetite. — Fair. 

Bowels. — Move  once  a  week,  "^-ith  cathartics. 

Weight. — One  year  ago  129  pounds  (normal) ;  6  months 
ago  125  (summer  weight);  present,  112. 


156  CANCER  OF  THE  STOMACH 

Examination. — Thin,  spare,  neurotic  Hebrew;  skin 
sallow;  slight  edema  about  ankles. 

Throat,  Neck  and  Chest. — Negative. 

Ahdomen. — Flat;  panniculus  thin;  no  tenderness.  In 
left  navel  region  is  a  freely  movable  mass  the  size  of  a 
tangerine  orange.     Stomach  is  moderately  dilated. 

Rectal  Examinaiion. — Hypertrophy  of  prostate. 
Laboratory  Examinations: 

Blood.—'Rg.,  75  per  eent.;r.b.c.,  4,500,000;  w.b.c,  11,000. 

Wassermann. — Negative. 

Urine. — Negative . 

Stool. — Brownish-yellow;  partly  formed;  hydi'obilii'U- 
bin+;  altered  blood +  . 

Test-meal. — Shght  12-hour  retention.  Contents,  pale 
yellow;  free  bleeding  on  lavage.  Total  aciditj^,  25;  free 
Hcl,  3;  lactic  acid,  0;  Wolff  + ;  altered  blood -f. 

Microscopic. — Several  groups  of  acid  fast  bacilli  of  Op- 
pler-Boas  Xy^Q. 

X-ray. — Fluoroscopy  demonstrates  filling  defect  of  py- 
lorus and  part  of  antrum.  ]Mass  is  freely  movable. 
Stomach  atonic  and  moderately  dilated. 

Laparotomy. — High  right  rectus  incision;  large  tumor 
involving  pyloric  third  of  stomach;  glands  moderately 
involved. 

Operation. — Partial  gastrectomy;  posterior  gastro-en- 
terostom5^ 

Pathology. — Adenocarcinoma. 

3.  Primary  Gastric  Cancer  icith  Few  Symptoms: 

Dr.  C.  H.  B. — ^Age  59,  American,  phj^sician. 

Family  History. — Nothing  important. 

Personal  History. — Tj-phoid  fever  25  j^ears  ago;  very  ill. 
Leg  lost  by  accident.     No  venereal  disease. 

Present  Trouble. — Had  ''nervous"  strain  5  months  ago. 
To  that  time  had  had  no  gastric  disturbance.  Four 
months  ago  began  to  belch  a  httle  gas  and  noted  a  slight 
gnawing  in  the  epigastrium  4  to  5  hours  after  taking  food. 
This  was  not  distressing. 

Appetite. — Remained  very  good. 

Bowels. — Negative  to  a  week  or  so  ago,  when  movements 
became  rather  loose;  never  any  blood. 


SYMPTOMATOLOGY  157 

Strength  and  endurance  remained  excellent. 

Weight. — One  year  ago  165;  6  months  ago  155;  present, 
140. 

Examination. — Tired  looking,  but  well-nourished  male. 
Tanned  skin,  but  mucosae  rather  pale. 

Throat. — Negative;  neck  negative. 

Thorax. — Negative. 

Abdomen. — Deep  tenderness  over  gall-bladder.  Sensa- 
tion of  deep  resistance  over  mid-epigastrium,  with  dulness 
on  percussion. 

Rectal  Examination. — Negative. 
Laboratory  Examinations: 

Blood.— Rg.,  80  per  cent.;  r.b.c,  4,200,000;  w.b.c,  6,000. 

Urine. — 0. 

Stool. — Altered  blood,  trace. 

Test-meal. — Moderate  12-hour  retention.  Total  acidity, 
8;  free  Hcl,  0;  lactic  acid,  trace;  Wolff -h;  altered  blood -h; 
several  bacilli  of  Oppler-Boas  type  seen. 

X-ray  Examination. — Filling  defect  of  pars  media  and 
posterior  wall;  malignant  hour-glass. 

Laparotomy. — High  right  rectus  incision.  Large  car- 
cinoma involving  pars  media;  lesser  curvature;  posterior 
wall  and  pancreas.     Irremovable. 

Pathologic  Report. — Gland  showed  carcinoma. 


Group  VI.  Gastric  Cancer  Secondary  to  an  Extragastric  Malignant  Process 

Such  instances  are  rare.  Our  series  comprises  16  cases 
(1.7  per  cent.).  The  disease  secondarily  invades  the 
stomach  either  by  contiguity  or  by  metastases  through  the 
lymph  stream.  We  have  records  of  5  cases  where  gastric 
cancer  followed  cancer  of  the  breast,  3  instances  follow- 
ing malignant  disease  of  the  female  genitalia,  3  cases  of 
extension  to  the  stomach  of  a  hepatic  cancer,  2  where  cancer 
of  the  gall-bladder  spread  to  the  stomach,  and  3  cases  (2 
males  and  1  female)  of  gastric  malignancy  associated  with 
neoplasms  of  the  colon.  For  reasons,  often  purely  scientific, 
it  is  essential  to   differentiate  actual  metastases  to  the 


158  CANCER  OF  THE  STOMACH 

stomach  from  a  previously  existing  lesion,  e.g.,  ulcer,  which 
has  becom.e  mahgnant. 

History  of  previous  operation  upon  mahgnant  disease  of 
breast,  pelvic  organs  or  bowel  usually  direct  attention 
toward  the  stomach.  The  course  of  the  ailment  is  similar 
to  that  when  the  disease  has  occurred  primarily  in  the 
stomach.  Clinically  it  is  often  distressing  on  account  of 
its  association  with  recurrent  tumors  at  the  original  focus. 

The  cases  below  bring  out  the  essential  features  of  this 
group. 

1.  Cancer  of  the  Liver,  Jaundice,  Secondary  Invasions  of  the 
Stomach: 

Mr.  C.  H. — Age  53,  German,  railroad  man. 

Family  History. — Negative. 

Personal  History. — Negative. 

Present  Complaint. — Patient  claims  that  he  was  perfectly 
well  until  3  months  ago;  then  became  jaundiced.  This 
has  persisted  and  has  changed  from  a  canary  yellow  to  a 
greenish-yellow  tint.  Two  months  ago  began  to  vomit 
food,  lost  appetite,  became  drowsy  and  sleepy  and  mark- 
edly constipated.     Urine  has  been  of  very  dark  color. 

Weight  Loss. — Eighteen  pounds  in  2  months. 

Pain. — Has  had  no  pain  but  feeling  of  fullness  in  epigas- 
trium. 

Abdominal  Examination. — Patient  emaciated,  jaundiced 
deeply,  mucosa  rather  pale. 

Bowels. — At  present  loose.     The  liver  is  enlarged  extend- 
ing downward  to  within  one  finger  breadth  of  the  navel,  it 
is  very  tender.     The  tumor  moves  up  and  down  on  respira- 
tion. 
Laboratory  Examinations: 

Blood.— Kg.,  75  per  cent.  ;r.b.c.,  4,000,000;  w.b.c,  14,500. 

Test-meal. — Moderate  12-hour  retention;  total  acidity, 
22;  free  Hcl,  0;  lactic  acid  (?) ;  altered  blood -f ;  formol  index, 
26.2. 

Stool. — Altered  blood. 

Laparotomy. — ^Large  carcinomatous  mass  involving  two- 
thirds  of  the  Hver;  gall-bladder  much  distended  and  filled 


SYMPTOMATOLOGY  159 

with  a  whitish  pus-like  fluid;  pancreas  and  lesser  curvature 
of  stomach  invaded  by  a  hard,  nodular  growth. 

Operation. — Cholecystostomy. 

Pathology. — Gland  showed  carcinoma. 

2.  Lymphosarcoma  of  Colon: 

Mr.  J.  N.— Age  27,  Swede. 

Family  History. — Negative. 

Personal  History. — Well  until  2  years  ago,  at  that  time 
began  to  complain  of  pain  in  the  epigastrium  which  lasted 
2  or  3  days  and  was  usually  followed  by  diarrhea.  He  had 
several  of  these  spells  during  the  first  year  and  rather  more 
than  this  during  the  last  9  months.  Bowels  were  always 
constipated  but  he  never  passed  blood.  Abdomen  not 
infrequently  distended  and  at  that  time  patient  says  he 
can  hear  gurgling  sounds.  The  abdominal  distention  and 
the  pains  are  brought  on  by  solid  foods.  Two  and  a  half 
weeks  ago  he  felt  a  tumor  the  size  of  a  hen's  egg  in  left 
hypochondrium. 

Weight  Loss. — Twenty  pounds  in  last  6  months. 

Abdominal  Examination. — Patient  undernourished,  ane- 
mic. 

Heart  and  Lungs. — Negative. 

Abdomen. — Hernia  of  the  linea  alba  midway  between 
navel  and  xyphoid.  On  standing  a  small  tumor  pro- 
trudes at  this  point.  Just  above  the  level  of  the  navel 
in  the  left  hypochondrium  is  a  tumor  the  size  of  one's  fist. 
It  is  fixed  and  tender  on  palpation.  Percussion  of  the 
abdomen  reveals  a  moderate  amount  of  ascites.  No 
external  lymph  tissue  metastases  palpable. 

Blood.— Rg.,  60;  r.b.c,  3,200,000;  w.b.c,  9,600. 

Stool. — Altered  blood -h. 

Laparotomy. — Low  median  incision;  the  abdomen  is 
partly  filled  with  free  chylous  fluid.  There  is  a  large 
adherent  tumor  involving  the  large  intestine  just  below 
the  splenic  flexure,  adherent  to  the  stomach,  several  loops 
of  small  bowel  run  through  it. 

Operation. — Entero-enterostomy. 

Pathology. — Gland  showed  lymphosarcoma. 


CHAPTER  IV 
PHYSICAL  ABNORMALITIES 

The  General  Appearance. — In  the  group  of  cases  where 
gastric  cancer  is  shown  to  exist  only  upon  microscopic 
examination  of  extirpated  sections  of  the  stomach  wall  at 
laparotomy,  frequently  there  are  very  few  evidences  of  the 
disease  on  inspection.  If  the  patient  should  be  seen  at  a 
time  when  he  is  having  acute  exacerbation  of  his  ailment, 
evidences  of  malnutrition  are  usually  not  lacking. 

When  we  recall  that  the  clinical  appearances  of  such  cases 
simulate  those  of  chronic  gastric  ulcer,  we  can  readily 
understand  why  alterations  that  indicate  systemic  intoxica- 
tion of  the  malignant  type  are  absent. 

In  instances  where  early  cardiac  or  pyloric  stenosis  has 
occurred,  weight  loss  incident  to  the  failure  of  nutrition  as 
a  result  of  vomiting  is  apparent  in  the  disappearance  of 
subcutaneous  fat,  in  the  loose  skin  and  a  certain  pallor  of 
the  mucous  surfaces. 

In  patients  where  nausea  is  a  common  symptom,  distress 
is  plainlj^  indicated  in  the  face  by  constant  or  intermittent 
pallor  associated  with  profuse  perspiration.  The  annoy- 
ance from  pyrosis  is  frequently  reflected  in  the  face.  Belch- 
ing may  be  constant  and  audible. 

If  pain  is  a  prominent  symptom,  the  appearance  and 
attitude  of  the  patient  may  be  characteristic.  A  pecuUar 
drawn  look  about  the  corners  of  the  mouth,  the  facial 
expression  indicating  discomfort,  or  an  unusual  body  pos- 
ture (bent  over,  hands  over  epigastrium,  lying  on  one  side, 

160 


PHYSICAL   ABNORMALITIES  161 

etc.),  may  show  that  some  departure  from  the  normal 
is  taking  place. 

When  malignancy  has  hecome  well  established  the  proof 
that  such  exists  may  be  evident  to  even  the  casual  on- 
looker. There  is  a  peculiar  apprehensive,  or  again  re- 
signed, hopelessness  in  the  general  appearance  of  such 
patients.  This  is  shown  by  the  dull  eye,  the  sunken  cheek, 
and  the  posture.  Such  patients  seem  to  partly  collapse 
upon  sitting  down,  or  they  lie  in  bed  passively.  The  gait 
may  be  shufHing.  Ph\^sical  exertion  generally  leads  to 
rapid  exhaustion. 

In  addition  to  the  evidence  of  weight  loss,  as  shown  in 
the  scaly  skin,  disappearance  of  normal  fat  accumulations 
about  the  body,  the  sunken  eyes  and  the  scaphoid  appear- 
ance of  the  abdomen,  there  are  external  e^ddences  of 
anemia  which  impart  a  grayish- white  to  yellowish-tan 
cast  to  the  skin.  It  is  unusual  for  a  patient's  skin  to 
assume  canary-yellow  coloration,  or  for  it  to  be  moist  or 
oily,  associated  with  the  presence  of  a  nearly  normal 
amount  of  subcutaneous  fat  such  as  one  sees  in  essential 
anemias.  Occasionally,  however,  the  general  appearance 
is  strikingly  similar. 

The  mucous  surfaces  are  often  pale  and  dry.  The  tongue 
is  generally  heavily  coated.  It  frequently  shows  fissures 
and  hypertrophied  papillae.  There  is  usuallj^  marked 
fetor  ex  ore.  This  is  due  partly  to  accumulation  of  foul 
material  in  the  stomach,  the  presence  of  microorganisms 
and  food  detritus  in  the  mouth  and  bad  teeth.  The  last 
are  sometimes  strikingly  noticeable. 

Many  instances  of  gastric  cancer  have  decaying  teeth  and 

pronounced    pyorrhea    alveolaris.     "While    in    such    cases 

bad  teeth  have  existed  for  years,  it  sometimes  seems  as 

though   the   onset   of   malignancy   were   associated   with 
n 


162  CANCER  OF  THE  STOMACH 

rapid  deterioration  of  the  teeth,  together  with  the  appear- 
ance of  pyorrhea.  From  mouths  containing  poor  or 
dirty  teeth  may  frequently  be  isolated  amoebae,  flagellate 
protozoa,  leptothrix  or  a  multitude  of  pathogenic  micro- 
organisms. It  would  be  difficult  to  assume  that  the 
swallowing  of  such  foreign  substances  is  entirely  beneficial 
to  injured  gastric  mucosae. 

Edema  not  uncommonly  occurs  in  the  late  stages  of 
gastric  cancer.  It  is  rarely  general.  Usually  it  is  evident 
by  slight  puffiness  beneath  the  eyes  or  about  the  ankles. 
Where  anemia  has  developed  rapidly,  one  can  often  detect 
so-called  ''false  edema"  behind  the  malleoli.  We  have 
noted  only  a  few  instances  where  the  edema  reached  above 
the  knees.  In  such  instances  it  is  not  uncommon  to  find 
interstitial  nephritis  associated  with  the  malignant  disease. 

External  Evidences  of  Metastasis. — These  are  observed  in 
rather  definite  locations.  Perhaps  the  most  common 
external  evidence  of  secondary  malignancy  is  seen  in  the 
left  supraclavicular  space.  Here  the  deep  (or,  more  rarely, 
the  superficial)  lymph  glands  enlarge.  We  have  seen  1 
patient  in  which  the  metastasis  was  as  large  as  a  medium- 
size  grape  fruit.  Usually,  however,  the  glands  are  as 
large  as  marbles  or  walnuts.  They  are  commonly  discrete, 
but  may  be  confluent.  It  would  seem  that  the  reason  for 
the  frequent  metastasis  on  the  left  side  lies  in  the  fact 
that  the  thoracic  duct  empties  into  the  subclavian  vein 
near  where  this  gland  chain  is  located.  Metastases  are 
apparently  directly  carried  to  this  gland  chain,  and  im- 
planted there  quite  early  in  the  case  of  growths  where  there 
is  abundant  and  rapid  cellular  proliferation.  In  many 
such  instances  examination  of  the  mediastinal  lymph 
spaces  shows  no  evidence  of  metastasis  involvement. 

Where  there  has  been  metastasis  to  the  peritoneum  one 


PHYSICAL    .\BXORMALITIES  163 

may  observe  early  evidences  of  ascites.  In  such  abdomens, 
bulging  in  the  flanks,  "^hen  the  patient  is  recumbent,  may 
be  noted.  This  is  in  rather  striking  contrast  to  the  lack 
of  subcutaneous  fat  and  the  general  flatness  of  the  abdomen. 
When -such  patient  stands  or  lies  upon  the  side,  or  assumes 
the  knee-chest  position,  the  fiUing  out  of  the  abdomen  in 
the  dependent  portion  may  be  observed. 

Where  there  has  been  rather  rapid  emaciation,  enlarge- 
ment of  the  liver,  due  to  secondary  growths  carried  to  it 
through  the  portal  lymph  stream,  may  be  seen.  We 
have  noted  several  cases  where  small  nodular  infiltrations 
about  the  navel  were  prominent.  Only  rarely  does  one 
find  visible  evidence  of  metastasis  in  the  inguinal  glands. 

Nervous  Signs. — There  has  been  much  written  about 
patients  with  gastric  cancer  exhibiting  melanchoHa,  in- 
sanity and  other  psychoses.  We  have  never  observed  a 
case  in  which  such  were  markedly  present.  It  is  true  that 
almost  everj'  patient  who  appears  with  abdominal  tumor, 
rapid  weight  loss,  deficient  strength  and  other  evidences  of 
malnutrition,  is  greatly  concerned  regarding  his  exact 
status.  It  is  quite  natural  that  such  a  person  should  be 
grievously  depressed.  In  an  individual  whose  tempera- 
ment is  rather  unstable,  one  can  readily  conceive  that 
such  depression  might  amount  to  melanchoha,  with  even 
suicidal  manifestations.  In  highly  neurotic  Jews,  mental 
conditions  which  render  the  patient  utterly  irresponsible, 
may  be  expected. 

The  Weight  Loss. — As  we  have  before  stated,  in  the 
instances  where  the  clinical  picture  is  that  of  chronic, 
gastric  ulcer,  there  may,  or  may  not,  be  weight  loss,  accord- 
ingly as  the  patient  comes  under  observation  during  a 
period  of  exacerbation,  or  when  his  process  is  quiescent. 
Even  in  circumstances  where  malignancy  is  estabhshed, 


164 


CANCER    OF    THE    STOMACH 


one  may  see  but  slight  physical  evidences  that  such  pa- 
tients have  lost  much  weight.  Unless  a  careful  check  has 
been  kept  upon  the  weight,  the  general  appearance  may 
not  lead  one  to  suspect  that  there  had  been  a  pronounced 
decrease.  This  appUes  particularly  to  individuals  who 
have  been  markedly  over-nourished,  or  to  patients  of  the 
large,  '' raw-bone"  type  who  have  not  had  much  sub- 
cutaneous fat  to  lose.  In  the  average  case,  however,  it 
is  possible  to  judge  from  the  looseness  of  the  clothing  or 
from  the  flabbiness  of  the  muscles  that  there  has  been 
weight  loss. 

Table  15. — Nutrition 


Months 

Minimum  weight  loss, 
pounds 

Maximum  weight  loss, 
pounds 

3 

4 

50 

4 

8 

72 

5 

10 

42 

6 

8 

100 

7 

20 

50 

8 

11 

60 

9 

7 

75 

10 

25 

50 

11 

50 

50 

12 

3 

60 

14 

40 

40 

15 

75 

75 

18 

35 

65 

24 

20 

50 

30 

40 

60 

36 

20 

75 

Showing  Weight  Loss  in  Gastric  Cancer  According  to  Duration  of  Symp- 
toms.— (Author.) 

We  have  instances  where  the  disease  had  existed  for  3 
months,  6  months,  9  months  and  even  12  months,  where 
the  weight  loss  has  been  respectively  but  4  pounds,  8 
pounds,  7  pounds,  and  3  pounds;  in  other  cases  where  the 
disease  has  made  itseK  evident  for  such  periods,  the  weight 


PHYSICAL   ABNOEMALITIES  '    165 

loss  has  been  50, 100, 75,  and  60  pounds  respectively.  Table 
15  shows  the  average  minimum  and  maximum  weight 
losses  in  individuals  whose  ailments  have  been  evident  for 
from  3  months  to  3  years. 

It  will  be  noted  that  there  is  a  striking  variation  in  the 
rate  in  which  cancer  patients  lose  weight.  Certain  factors 
are  responsible  for  this : 

1.  The  Age  at  Which  the  Disease  Occurs. — While  no 
general  rule  can  be  formulated,  it  would  seem  that  cancer 
patients  past  the  age  of  60  lose  weight  less  rapidly  than  do 
those  who  are  attacked  by  the  disease  below  the  age  of 
40.  In  our  experience,  cancer  in  the  young  has  always  been 
attended  by  relatively  rapid  weight  loss  and  other  evi- 
dences of  cachexia.  We  have  seen,  however,  old  people 
lose  as  much  as  80  pounds  in  6  months. 

2.  Failure  to  Take  Sufficient  Food. — -This  may  be  due 
to  the  loss  of  appetite  which  early  appears  in  gastric 
cancer.  Food  desire  may  be  greatly  altered  so  that 
aversion  may  be  manifested  toward  those  things  which 
have  previously  been  eaten.  As  a  result  of  this,  the  pa- 
tient may  eat  very  Uttle,  not  knowing  that  with  a  change  of 
diet  food  may  be  taken  with  comfort  and  relish.  Constant, 
or  intermittent,  severe  pain  is  also  responsible  for  rapid 
weight  losses.  Many  individuals  are  afraid  to  eat  on 
account  of  bringing  on  or  aggravating  pain  by  so  doing. 

3.  Vomiting  not  Infrequently  Precipitates  Rapid  Weight 
Loss. — If  pyloric  obstruction,  obstruction  at  the  cardia, 
or  malignant  hour-glass  are  developed,  then  early  vomit- 
ing or  constant  nausea  may  result.  In  these  instances 
the  accumulation  of  foul  material  in  the  stomach  is  a  not 
altogether  negligible  factor  in  bringing  on  early  cachexia. 

4.  Condition  of  the  Mouth. — Poor  teeth,  missing  teeth 
or  sore.' mouth  may  render  it  impossible  for  a  patient  to 


166  CANCER  OF  THE  STOMACH 

properly  masticate  food,  or  to  take  food  which  has  definite 
strength-giving  composition. 

5.  The  Poor-appetite  Habit. — Many  individuals  with 
gastro-intestinal  troubles  are  literally  ''dieted  to  death." 
In  the  attempt  to  work  out  various  novel  theories 
regarding  nutrition  and  metabolism,  well-meaning  in- 
dividuals not  infrequently  suggest  dietetic  regimes  which 
are  entirely  foreign  to  the  human  family.  Some  of  these 
are  sufficiently  distasteful  to  ''gag  a  buzzard."  If  the 
individual  has  a  long  precancerous,  gastric  history  (fre- 
quently that  of  gastric  ulcer)  the  poor-appetite  habit  may 
be  already  well  developed  at  the  time  when  the  cancerous 
process  begins. 

6.  Mental  Attitude. — It  is  not  uncommon  to  find  indi- 
viduals who,  upon  learning  that  there  is  a  possibility  of  a 
malignant  disease  developing,  or  having  developed,  assume 
such  an  attitude  of  general  disinterestedness  in  life  and 
the  things  which  pertain  to  it  that  not  only  are  dietetic 
principles  unheeded,  but  the  general  condition — the  care 
of  the  teeth,  skin,  kidneys,  bowels  and  the  like — ^is  entirely 
neglected.  In  such  individuals,  it  seems  that  weight  loss 
progresses  very  rapidly. 

THE  ABDOMINAL  EXAMINATION 

General  Considerations. — Experience  has  impressed  upon 
us  the  necessity  of  properly  preparing  patients  for  ab- 
dominal examination,  and  also  of  carrying  on  such  in- 
vestigation under  favorable  circumstances. 

Whenever  possible,  abdominal  examination  should  be 
conducted  with  the  hollow  viscera  empty.  If  the  stomach 
and  bowels  are  filled  with  feces  and  gas,  even  those  most 
expert  in  diagnosis  may  fail  to  detect  abnormalities. 
Many  a  so-called  clever  diagnosis  has  its  foundation  upon 


PHYSICAL   T^NORMALITIES  167 

thorough  gastric  lavage  and  vigorous  catharsis  previous 
to  the  carrying  out  of  the  abdominal  examination. 

Our  practice  is  to  administer  2  ounces  of  castor  oil,  in 
a  half  glass  of  beer,  malt-extract  or  acid  fruit-juice,  12 
hours  before  the  patient  appears  for  study.  If  the  bowels 
have  not  moved  freely  after  this  interval,  an  enema  of 
soap-suds  and  warm  water  is  then  administered.  A  few 
obstinate  cases  require  more  potent  enemata.  We  have 
found  that  in  such  instances  the  old-fashioned  glycerin 
and  salts  clystra  usually  answers  very  well.  But  rarely 
has  it  been  necessary  to  use  so  formidable  an  enema  as  that 
composed  of  milk  and  molasses,  warmed  (milk  600  cc; 
New  Orleans  molasses  400  cc;  mix  thoroughly;  warm  to 
37°  C;  inject  in  the  usual  manner).  If  the  lower  bowel  is 
clogged  with  hardened  feces,  this  enema  is  generally  effect- 
ive where  other  types  have  failed. 

Just  previous  to  the  abdominal  examination,  the  patient's 
stomach  is  emptied  with  the  aid  of  a  stomach  tube  of  large 
caliber.  After  a  fruitless  search  for  a  tube  that  would 
enable  us  to  free  the  stomach  of  the  foul  mixture  which  it 
often  contains  where  the  pylorus  is  stenosed,  or  when  hour- 
glass contraction  has  occurred,  we  devised  the  stomach 
tube  described  in  Chapter  V.  Lavage  with  such  tube, 
using  2  or  3  liters  of  warm  normal  salt  solution,  usually 
empties  even  the  most  dilated  or  malformed  stomach  in  a 
short  time. 

Following  lavage,  the  patient  should  be  stripped  of  all 
clothing,  at  least  to  the  waist.  We  prefer  to  have  patients 
appear  for  examination  clad  in  only  a  thin,  readily  removed 
night-shirt  or  kimono.  Some  improperly  educated  folk — 
physicians  as  well  as  laymen — still  believe  that  dependable 
abdominal  diagnoses  can  be  made  without  exposing  the 
area  of  suspected  disease.     This  applies  especially  in'!' the 


168  CANCER   OF   THE    STOMACH 

case  of  females.  Yet  such  modestce  regularly  display  their 
anatomical  perfections,  wherever  these  may  exist,  to  the 
eyes  of  the  multitude  in  order  to  partake  of  the  psychic 
comfort  supplied  by  the  "fox  trot"  or  the  ''bunny  hug." 
Proper  abdominal  examination  cannot  be  made  unless 
the  abdomen  can  be  seen,  felt  and  listened  to.  The 
ingenious  American  union-suit  and  its  equally  unsanitary 
rival,  the  fashionable  corset,  coupled  with  the  ''don't-let- 
me-annoy-you "  attitude  of  the  popular  attendant,  with  a 
medical  license,  are  often  responsible  for  gastric  cancer 
reaching  hopelessly  inoperable  stages  before  such  is  even 
suspected  to  exist. 

Nervous  or  excitable  individuals  sometimes  require  a 
quieting  potion  before  being  examined.  Thirty  grains  of 
sodium  bromid  in  a  wine-glass  of  an  gostura  bitters  usually  aid 
these  unfortunates.  An  attitude  on  the  part  of  the  physi- 
cian that  inspires  confidence  is  better  therapy,  however. 

We  prefer  routinely  to  examine  the  patient  as  he  lies 
upon  a  table  with  his  feet  toward  an  unshaded  window. 
His  head  should  rest  upon  a  small,  firm  pillow.  The  room 
should  be  clean,  quiet,  warm  and  not  draughty.  The 
physician's  hands  should  be  warm  and  unsoiled.  In  this 
age  of  motor  cars,  both  these  cautions  are  appropriate. 

A  general  physical  examination  should  always  precede 
the  special  study  of  the  abdomen.  The  type  of  ''ab- 
dominal specialist"  who  can  tell  that  an  enlarged  liver  is 
not  due  to  a  tricuspid  regurgitation  or  a  nodular  omentum 
not  secondary  to  a  pulmonary  tuberculosis,  without  exami- 
nation of  the  primary  focus  of  disease,  is  fortunately  be- 
coming an  extremely  rara  avis.  All  the  information  that 
it  is  possible  to  derive  from  chemic,  microscopic,  serologic 
or  roentgenographic  investigation  should  supplement  the 
physical  examination. 


PHYSICAL   ABNORMALITIES  169 

1.  Inspection  may  return  no  facts  of  clinical  value  in 
those  cases  where  early  carcinomatous  change  exists  in 
the  border  of  a  peptic  ulcer.  Unless  in  severe  pain,  the 
patient  lies  at  ease.  The  skin  may  be  of  good  color  and 
sleekly  stretched  over  normal  amounts  of  subcutaneous 
fat.  The  normal,  bony  boundaries  of  the  belly  may  be  well 
hidden.  Cancerous  change  cannot  exist  long,  however, 
before  weight  loss  and  cachexia  are  apparent.  The  fat 
of  the  abdominal  parietes  is  usually  diminished  early.  As 
a  consequence,  pale,  dry,  loose,  wrinkled  skin  covers  the 
belly  and  sags  down  in  more  or  less  marked  folds  in  the 
flanks.     Its  hairy  adnexa  are  often  dry  and  brittle. 

The  rib  margins  and  the  pelvic  bones  may  become  strik- 
ingly prominent.  If  an  extensive  neoplasm  is  present, 
degenerative  changes  take  place  in  the  muscle  layers  of  the 
abdominal  wall,  resulting  in  their  loss  of  tone.  As  a 
consequence,  the  belly  appears  flat  or  scaphoid.  Not 
rarely  a  scaphoid  or  flat  abdomen  may  have  local  areas 
of  prominence  due  to  visible  gastric  tumor,  enlarged  liver 
or  pancreas,  or  metastases  to  the  navel,  omentum,  or 
inguinal  lymph  nodes.  Where  free  fluid  is  present  in  the 
peritoneal  sac,  but  the  peritoneal  sac  not  filled,  bulging  in 
the  flanks  may  be  observed.  This  usually  shifts  with 
change  of  the  patient's  position.  If  there  is  a  great  ac- 
cumulation of  fluid,  the  abdomen  may  appear  rounded. 
The  navel  may  bulge. 

Should  marked  emaciation  have  taken  place,  pulsations 
of  the  abdominal  aorta  are  readily  observed.  They  were 
recorded  in  129  instances  (15.01  per  cent.)  of  our  series. 

Local  abdominal  pro7ninences  are  due  to  the  presence  of  a 
primary  tumor,  its  metastases,  encapsulated  collections 
of  fluid  or  air,  or  visibility  of  normal-size,  solid  organs  as  a 
result  of  extreme  emaciation  (liver)  or  hardened  feces. 


170  CANCER  OF  THE  STOMACH 

Respiratory  movements  cause  certain  alterations  in  the 
abdominal  contour.  Tumors  of  the  stomach  and  in- 
testines usually  change  their  position,  and  frequently  their 
shape  during  respiration.  Such  prominences  as  occur 
from  enlargement  of  the  pancreas,  abdominal  aneurysm, 
retroperitoneal  sarcoma,  hypernephroma  or  various  non- 
malignant  tumors  of  the  abdominal  wall  itself,  may  show 
no  appreciable  alteration  during  inspiration  and  expira- 
tion. Not  infrequently,  in  an  emaciated  person,  ripples  or 
indefinitely  outlined  shadows  are  produced,  by  vigorous 
respiratory  efforts,  when  free  fluid  exists  in  the  peritoneal 
sac. 

Change  of  position  causes  important  alterations  in  the 
appearance  of  the  abdomen.  Frequently  when  a  patient 
lies  upon  either  side,  stands,  or  assumes  the  knee-chest 
posture,  local  or  general  bulging  may  occur  from  intra- 
abdominal tumors  or  fluid.  This  is  a  valuable  maneuver 
and  should  not  be  neglected  in  doubtful  cases. 

Visible  peristalsis  of  stomach  or  intestines,  or  both,  is 
not  rarely  made  out  when  obstruction  occurs  (complete  or 
partial)  at  the  pylorus  or  in  the  small  bowel.  Occasion- 
ally where  there  is  a  secondary  or  primary  malignant 
involvement  of  the  transverse  colon,  local  out-pouchings, 
usually  on  the  proximal  side  of  the  obstruction,  may  be 
made  out.  While  these  do  not  as  a  rule  show  active  peri- 
staltic waves,  the  variation  in  size  of  the  bulging  at  dif- 
ferent examinations  suggests  the  complication. 

When  a  malignant  obstruction  occurs  at  the  outlet  of  the 
stomach  the  dilatation  of  the  viscus  is  usually  prompt  and 
may  be  very  extensive. 

In  the  early  stages  of  gastric  cancer  before  there  has  been 
secondary  degeneration  of  muscle  fibers  in  the  stomach 
wall  the  peristalsis  remains  active.     A  vigorous  attempt 


PHYSICAL    ABNORMALITIES  171 

is  made  to  force  gastric  contents  through  the  narrow  out- 
let. If  the  abdominal  wall  is  not  too  thick,  one  readily 
perceives  rhythmie  waves  passing  from  the  left  rib  edge 
across  the  epigastrium.  Such  waves  are  usually  more 
evident  toward  the  pyloric  region.  They  may  occur  so 
vigorously  that  the  pylorus  is  brought  forward  toward 
the  anterior  abdominal  wall  and  may  appear  as  an  evan- 
escent ''phantom  tumor." 

Kussmaul  first  described  this  phenomenon  in  a  case  of 
non-malignant  pyloric  stenosis.  It  appeared  in  12.2  per 
cent,  of  our  cases  where  the  pylorus  was  extensively  involved. 
When  the  obstruction  is  marked,  as  in  early  scirrhus  cancer 
developing  in  the  edge  of  a  chronic  annular  ulcer,  reverse 
peristaltic  waves  may  be  observed.  These  pass  from  the 
right  to  the  left  across  the  epigastrium.  They  are  rarely  so 
well  evidenced  as  are  peristaltic  waves  in  the  normal  direc- 
tion. In  a  good  light,  with  the  observer's  eyes  at  the  level 
of  the  stomach,  they  may  be  seen  to  develop  in  the  right 
upper  quadrant  and  fade  away  indefinitely  toward  the 
mid-  or  left  epigastrium.  When  seen  they  always  indicate 
a  marked  grade  of  pyloric  stenosis.  We  have  observed 
reverse  peristalsis  in  9  cases.  Sometimes  visible  peristalsis 
may  be  brought  out  by  gently  tapping  the  abdomen  or  by 
several  rather  sudden  ''dipping"  movements  upon  the 
epigastrium. 

If  the  obstruction  occurs — and  this  is  very  uncommon — 
in  the  small  intestine,  rather  slowly  forming,  transient 
swellings,  resembling  the  movements  of  an  angle  worm,  may 
be  made  out  in  the  low  epigastrium  or  below  the  navel. 
It  has  been  stated  that  such  movements  assume  character- 
istic patterns  depending  upon  the  part  of  the  small  bowel 
obstructed.  We  have  never  been  able  to  satisfy  ourselves 
that  these  tumor  patterns  had  any  special  diagnostic  sig- 


172  CANCER  OF  THE  STOMACH 

nificance  with  regard  to  enabling  us  to  accurately  prophesy 
where  the  obstructive  point  would  be  at  laparotomy. 

Enlarged  lymph  nodes  may  be  observed  in  the  super- 
ficial inguinal  chain.  They  rarely  attain  so  great  a  size 
as  do  metastases  to  the  glands  of  the  neck  or  the  axilla. 
Sometimes  a  metastasis  occurs  directly  to  the  navel. 
This  usually  results  in  a  retracted,  malformed,  fixed  um- 
bilicus. It  occurred  in  59  (6.4  per  cent.)  of  our  cases. 
Very  rarely  one  sees  a  surface  ulceration  of  such  a  met- 
astasis. This  is  not  apt  to  be  extensive,  but  if  secondary 
infection  takes  place,  a  granulomatous  tumor  may  result. 
We  have  seen  several  instances  where  a  perforated,  anterior- 
wall  ulcer  resulted  in  accumulation  of  pus  in  the  region  of 
the  navel.  Such  may  closely  simulate  a  metastasis  from 
gastric  malignancy. 

2.  Palpation. — From  this  maneuver  we  gain  the  greatest 
amount  of  information  regarding  the  abdomen  in  malig- 
nant disease.  One  should  guard  against  hasty  and  vigorous 
palpation.  The  patient  should  be  accustomed  to  light 
movements,  pressure  of  the  fingers,  or  the  flat  of  the  hand, 
before  attempts  are  made  to  palpate  deeply  lying  structures 
with  the  tips  of  the  fingers.  Particularly  in  the  case  of 
the  abdomen,  where  the  history  of  the  patient  is  not  clear, 
or  has  not  been  obtained,  or  where  it  is  suspected  that  such 
a  complication  as  hemorrhage  or  perforation  has  taken 
place,  light  palpation  is  an  essential  requisite  for  safety. 
It  is  well  to  accustom  the  subject  to  pressure  of  the  hand 
over  areas  in  which  the  disease  is  not  suspected,  before 
exploring  disease  foci. 

The  tension  of  the  abdominal  wall  in  well-established 
malignancy  is  diminished  unless  there  has  been  exten- 
sive involvement  of  the  peritoneum  with  or  without 
the   accumulation    of   free    fiuid.     In   early   malignancy, 


PHYSICAL    ABNORMALITIES  173 

where  a  previously  complicated  ulcer  is  undergoing  can- 
cerous change,  the  abdominal  wall  tension  may  be  nor- 
mal or  even  increased  locally  or  generally.  This  is  par- 
ticularly the  case  where  a  recent  hemorrhage  has  occurred, 
perforation  of  an  ulcer  has  taken  place,  or  where  great 
pain  results  in  the  patient's  unconsciously  tightening  the 
abdominal  muscles.  In  such  event  it  is  almost  im- 
possible to  successfully  examine  the  intra-abdominal 
organs  without  the  patient  being  given  an  anesthetic,  or 
unless  he  has  lain  for  from  15  minutes  to  3^  hour  in  a  bath 
tub  filled  with  water  above  373^-^°  C  The  latter  diagnostic 
maneuver  is  one  of  a  few  real  advances  in  abdominal  ex- 
amination that  has  been  made  in  this  countrj^  during  the 
past  15  years.  Its  use  has  been  emphasized  particularly 
by  Dock.  We  have  found  it  an  almost  invaluable  aid  in 
the  examination  of  hypersensitive  indi^dduals,  or  in  in- 
stances where  perforation  or  obstruction  have  been  sus- 
pected. After  the  patient  has  been  in  the  hot  water  for 
the  required  time,  the  abdomen  can  be  examined  while  he  is 
still  submerged,  or  immediately  after  he  has  been  removed 
from  the  bath,  dried  and  placed  upon  an  examining  table 
in  a  rather  warm  room.  We  have  never  found  it  necessary 
to  administer  a  general  anesthetic  in  order  to  facihtate  an 
abdominal  examination.  There  may  be  cases,  however,  in 
which  such  a  procedure  is  entirely  justifiable. 

The  palpating  hand  in  gastric  cancer  usually  notes  at 
once  the  temperature,  dryness,  scaliness  and  looseness  of 
the  skin  covering  the  abdomen.  Xot  infrequently,  due  to 
the  rapid  disappearance  of  subcutaneous  fat,  the  skin  may 
be  raised  by  the  fingers  several  inches  above  the  level  of 
the  abdomen.  It  falls  back  slowly  and  in  loose  folds  due 
to  the  diminution  of  its  elasticity.  Occasionally,  between 
the  skin  and  the  muscular  waU,  or  superficially  in  the  mus- 


174  CANCER  OF  THE  STOMACH 

cular  wall,  one  is  able  to  feel  small  nodules  or  even  tumors. 
These  so-called  "Nelaton"  tumors  are  not  infrequently 
confused  with  the  tumor  resulting  from  gastric  malignancy. 
Lipomata  are  rarely  deliixdted  over  the  abdomen  in  this 
disease.  Infiltration  of  the  navel  can  be  usually  well  made 
out  if  it  is  present.  The  navel  remains  more  or  less  stiff- 
ened, fixed  and  adherent  deeply.  Sometimes  inguinal 
glands  that  cannot  be  seen  are  palpable.  They  are  rarely 
tender  to  pressure.  The  muscular  wall  in  even  moderately 
advanced  cancer  is  loose  and  lax.  If  much  weight  has  been 
lost  it  is  apt  to  be  very  thin  and  the  deeper  structures 
easily  made  out  through  it. 

In  instances  where  an  accumulation  of  fluid  has  distended 
the  peritoneal  sac,  the  muscular  waU  while  evidently 
thin  is  stretched  and  tight.  Such  abdomens  may  be  tender 
if  there  has  been  a  very  extensive  accumulation  of  serum. 
Unless  there  is  very  great  distention  of  the  abdomen  by 
fluid,  or  unless  the  fluid  is  accumulated  in  small,  well 
walled-off  pockets  due  to  the  extensive  involvement  of 
the  omentum  and  mesentery,  one  can  usually  demonstrate 
by  tapping,  fluctuating  waves  of  greater  or  less  definiteness. 

Deep  palpation  of  the  abdomen  causes  pain  in  the 
majority  of  instances.  As  a  general  rule,  the  epigastric 
distress  on  palpation  is  greater  in  early  cancer  developing 
upon  ulcer,  or  in  primary  cancer  which  has  later  ulcerated, 
than  it  is  where  there  has  been  an  extensive  or  rapid  growth 
of  the  neoplasm.  In  instances  where  a  recent  hemorrhage 
has  occurred  or  perforation  with  inflammatory  change 
in  the  peritoneum  has  taken  place,  the  pain  upon  palpation 
may  be  as  marked  as  in  the  acute  abdomen  due  to  other 
diseases  (appendicitis,  gall-stones  and  the  like). 

If  there  has  been  much  emaciation,  the  normal  organs 
may   be   palpated   with   greater   ease   than   usual.     This 


PHYSICAL   ABNORMALITIES  175 

applies  especially  to  the  liver,  kidneys,  the  abdominal 
aorta,  the  bowels  or  the  pancreas.  Some  of  these  may 
be  invaded  by  secondary  growths. 

The  most  important  palpatory  sign  in  gastric  cancer  is 
the  determination  of  the  presence  or  absence  of  an  ab- 
dominal tumor  associated  with  the  stomach. 

THE  ABDOMINAL  TUMOR 

(a)  Incidence. — In  the  observation  of  150  cases  clinic- 
ally diagnosed  gastric  cancer,  Osier  and  IMacCrae  report 
the  presence  of  palpable  tumor  in  76  per  cent.  The  Fen- 
wicks  studied  154  instances  of  the  disease.  In  69  per 
cent,  there  were  definitely  demonstrated  nodules;  in  an 
additional  8  per  cent.  '411-defined  tumor"  or  ''sense  of 
resistance"  were  recorded.  Earher  investigators  (Brinton, 
Lebert,  Leube,  Hahn)  place  the  tumor  frequency  at  from 
80  to  86  per  cent.  In  a  recent  study  of  1,000  cases  clinically, 
gastric  cancer  (only  26.6  per  cent,  came  to  laparotomy) 
Friedenwald  reports  the  presence  of  recognizable  abdom- 
inal ridge  or  mass  in  71.9  per  cent. 

The  above  figures  exhibit  a  range  of  about  17  per  cent. 
The  stage  during  which  the  disease  came  under  observation, 
and  the  skill  possessed  by  the  individual  examiner,  doubtless 
account  for  the  seeming  discrepancy  in  tumor  incidence. 

Of  the  921  instances  of  operated  and  pathologically 
demonstrated  gastric  cancer  making  up  our  series,  ab- 
dominal tumor  or  ridge  was  palpated  in  609  (66.1  per  cent.). 
From  this  analysis  all  such  doubtful  things  as  ''ridges," 
"indurations"  or  "resistances"  have  been  excluded. 

There  were  312  cases  (33.7  per  cent.)  in  which  abdominal 
tumor  was  not  recorded  as  being  palpable.  One  source  of 
failure  was  undoubtedly  the  earliness  with  which  some  of 
the  cancers  were  diagnosed.     TMiere  the  proof  of  gastric 


176 


CANCER   OF   THE    STOMACH 


malignancy  rests  upon  microscopic  examination  of  extir- 
pated tissue,  only  rarely  is  it  possible  to  demonstrate  tumor 
before  laparotomy.  Other  reasons  varying  the  possibility 
of  tumor  recognition  are:  the  care  with  which  the  abdo- 
men has  been  palpated;  the  skill  of  the  examiner;  the 
preparation  of  the  patient;  the  position  in  which  he  has 
been  studied  (examination  in  the  knee-chest,  lateral  or 
sitting  positions,  with  or  without  the  added  advantage  of 
deep  breathing  or  the  hot  bath,  often  aid  in  the  discovery 
of  an  abdominal  mass);  the  relative  accessibility  of  the 
growth  (neoplasms  near  the  cardia,  at  the  fundus  and  on 
the  posterior  wall  are  delimited  with  difficulty);  the  type 
of  growth  (encephaioid  cancers,  confining  themselves  largely 
to  the  submucosa,  are  not  so  readily  palpated  as  are  local- 
ized, nodular,  fibrous  tumors) ;  the  tension  or  thickness 
of  the  parietes;  the  pain  caused  by  palpation  and  the  pres- 
ence of  metastases  (tumor  of  the  hver,  omentum  or  colon  or 
the  existence  of  ascites). 

(6)  Position  of  the  Tumor. — In  515  instances  (85.7 
per  cent.)  the  palpable  nodule  or  mass  was  located  in  the 
epigastrium  proper.     In  86  cases  (13  per  cent.)  the  growth 


Table  16 


Location 

Number  of  cases 

Per  cent. 

Right  upper  quadrant . . 
Left  upper  quadrant .... 

Mid-epigastrium 

"Pit"  of  stomach 

Epigastrium,  general 

At  navel 

199 
165 
73 
47 
31 
27 
38 
21 
8 

32.6 

27.1 

11.9 

7.7 

5.1 

4.4 

Right  of  navel 

6.2 

Left  of  navel 

3.4 

Below  navel 

1.3 

Total 

609 

99.7 

Position  of  Abdominal  Tumor  in  Gastric  Cancer. — (Author's  Cases.) 


PETTSICAL    ABNORMALITIES  177 

was  found  in  the  region  of  the  navel  or  at  about  its  level. 
But  8  times  (1.3  per  cent.)  was  the  tumor  below  the  level 
of  the  navel.  Table  16  gives  in  detail  the  locations  of  the 
growth  with  the  patient  in  the  dorsal  position. 

(c)  Relation  of  Position  of  Abdominal  Tumor  to  Part  of 
Stomach  Involved. — Our  study  shows  that  in  66.7  per  cent, 
of  instances  the  neoplasm  involved  the  pylorus,  antrum 
and  the  lesser  curvature.  Approximately  8  out  of  10  such 
growths  were  palpated  before  laparotomy.  In  12  per 
cent,  the  greater  part  of  the  stomach  had  been  invaded. 
]More  than  9  out  of  10  of  these  were  palpable.  The 
posterior  wall  was  the  seat  of  the  disease  in  9.3  per  cent. 
In  this  group,  tumor  could  be  felt  externalh*  in  but  5 
out  of  10.  The  anterior  waU  was  involved  in  2.3  per  cent. 
These  growths  were  palpable  in  9  out  of  10  instances. 
In  3.0  per  cent,  of  oiu'  cases  the  growth  was  at  or  near 
the  cardia.  But  3  out  of  10  such  tumors  were  palpable. 
The  greater  curvatiu'e  was  involved  in  2.3  per  cent,  and 
6  out  of  10  such  tumors  were  delimited  tkrough  the  ab- 
dominal wall.  None  of  the  tumors  invading  the  fundus 
were  palpable.  Some  part  of  the  multiple  tumors  form- 
ing 2.9  per  cent,  of  oiu'  cases  was  palpated  in  more  than  9 
out  of  10  instances. 

Factors  other  than  anatomic  location  of  the  gastric 
neoplasm  which  modify  its  ease  of  palpation  have  already 
been  enumerated.  In  addition,  we  would  emphasize  that 
ver}'  frequently  tumors  are  rendered  palpable  and  even 
visible  by  inflation  of  the  stomach  with  ah  or  gas,  either 
by  means  of  a  Davidson  double-bulb  syringe  through  a 
stomach  tube,  or  by  the  administration  of  4  grams  of 
tartaric  acid  in  50  cc.  of  water,  followed  by  -4  grams  of 
sodium  bicarbonate  in  50  cc.  of  water,  or  by  filling  the 
viscus  with  fluid.     It  should  be  likewise  emphasized  here 

12 


178  CANCER  OF  THE  STOMACH 

that  distention  of  the  stomach  or  filling  it  with  liquid  not 
infrequently  cause  a  tumor  already  palpable  to  disappear. 
This  is  particularly  apt  to  occur  in  the  event  that  the 
neoplasm  involves  the  posterior  wall,  greater  curvature  or 
the  antrum.  It  is  good  practice  to  examine  all  stomachs 
suspected  to  be  the  seat  of  malignant  growths  both  before 
and  after  air  distention,  or  filling  with  water. 

{d)  Size  of  the  Tumor. — Ulcera  carcinomatosa  may  be 
felt  only  as  narrow  finger-like  ridges  or  small  nodules,  both 
before  or  after  gastric  filling.  Other  cancers  range  in 
size  at  palpation  from  that  of  a  common  marble  to  as 
great  as  a  child's  head,  a  medium-size  squash  or  a  discus. 
The  tumor  may  fill  the  entire  epigastrium  and  extend 
well  into  the  left  flank.  It  may  be  so  large  as  to  simulate 
a  leukemic  spleen.  If  invasion  of  the  liver,  pancreas  or 
adjacent  hollow  viscera  has  taken  place,  a  huge,  irregular, 
plaque-like  mass  may  occupy  the  entire  upper  epigastrium. 
Rarely  does  the  growth  extend  below  the  navel,  but  if  the 
omentum  is  involved,  the  tumor  may  be  so  extensive  as 
to  cast  doubt  upon  its  being  primarily  gastric  in  origin. 

(e)  Tenderness  of  palpable  tumors  varies  in  degree  from 
vague  discomfort  to  actual  pain.  With  the  exception  of 
ulcera  carcinomatosa  it  is  uncommon  to  have  gastric 
cancer  patients  experience  so  much  distress  upon  palpa- 
tion as  do  those  affected  with  benign  peptic  ulcer.  Even 
where  malignant  perforation  has  taken  place,  the  resultant 
peritoneal  invasion  is  accompanied  by  less  pronounced 
evidences  of  inflammatory  reaction  than  where  this  com- 
plication occurs  in  benign  affections. 

There  are  but  few  gastric  cancers  which  fail  to  exhibit 
some  tenderness  upon  palpation.  Of  572  instances  where 
definite  information  is  available  in  our  series,  34  patients 
(5.9  per  cent.)  complained  of  no  discomfort  upon  the  manual 


PHYSICAL   ABNORMALITIES  179 

examination  of  the  growth.  Of  the  538  cases  remaining, 
in  401  instances  (70.1  per  cent.)  there  was  some  degree  of 
discomfort  exhibited;  in  137  cases  (24  per  cent.)  palpa- 
tion was  noticeably  painful.  Of  our  entire  series  of  921 
cases  furnishing  the  basis  of  this  study,  there  were  122  in- 
stances (13.3  per  cent.)  where  some  grade  of  perforation 
existed  at  laparotomy,  and  an  additional  81  cases  (8.8 
per  cent.)  where  the  serous  surface  of  the  stomach  had 
been  definitely  involved  in  the  malignant  disease.  From 
a  consideration  of  these  figures,  it  would  seem  that  pro- 
tected perforation  or  peritoneal  invasion  without  perfora- 
tiou  may  be  present  and  their  existence  not  be  recognized 
even  upon  careful  abdominal  palpation. 

(/)  Mobility  of  the  Abdominal  Tumor. — Factors  influenc- 
ing the  demonstration  of  the  mobility  of  the  palpable  tumor 
in  gastric  cancer  are:  the  histologic  type  of  tumor;  the 
duration  of  its  growth;  the  position  it  occupies  in  the 
wall  of  the  viscus;  its  relation  to  complications  (perfora- 
tion, adhesions,  contiguous  extension,  fluid  in  the  peri- 
toneal sac);  the  position  in  which  the  patient  is  examined; 
its  behavior  when  the  stomach  or  colon  is  filled  with  air 
or  fluid;  the  thickness  of  the  abdominal  parietes  and  the 
respiratory  movements. 

While  the  majority  of  gastric  cancers  exhibit  some 
freedom  of  movement,  in  only  437  instances  (71.7  per  cent.) 
of  our  cases  was  it  possible  to  definitely  move  about  the 
tumor  with  the  palpating  fingers.  The  remaining  growths 
were  either  located  in  relatively  fixed  parts  of  the  stomach 
or  had  been  more  or  less  immobilized  during  their  develop- 
ment. 

It  is  of  considerable  importance  to  demonstrate  me- 
chanical mobility  (i.e.,  by  the  fingers)  of  gastric  neoplasms, 
inasmuch  as  those  in  which  the  greatest  freedom  of  move- 


180  CANCER  OF  THE  STOMACH 

ment  is  demonstrated  are  generally  most  successfully 
treated  surgically. 

The  histologic  type  of  the  necplasm  qualifies  its  freedom 
of  movement.  Cancers  developing  in  ulcer  edges,  or  can- 
cers rich  in  fibrous  elements  in  which  ulceration  has  oc- 
curred thi-ough  surface  necrosis  are  apt  to  be  more  mobile 
than  so-called  ''primary"  gastric  neoplasms  of  the  med- 
ullary or  colloid  types.  It  will  be  recalled,  moreover,  that 
2  out  of  3  tumors  are  located  in  the  p^doric  third — a  por- 
tion of  the  stomach  which,  normally,  has  the  greatest 
range  of  displacement.  In  this  part  of  the  stomach  the 
muscle  layers  are  also  densest.  It  would  seem  that  such 
might  interpose  a  strong  barrier  to  the  rapid,  external  spread 
of  the  disease.  General  involvement  of  the  stomach  by  a 
tumor  of  the  clinically,  scirrhus  tj'pe,  permits  freedom  of  the 
viscus  for  the  longest  time.  Extensive  perigastric  lymph- 
gland  invasion  may  hmit  such  mobility. 

The  duration  of  the  disease  affects  the  mobiUty  of  gastric 
tumors  only  in  a  general  way.  We  have  akeady  emphasized 
that  cell  proliferation  may  occur  with  astonishing  rapidity 
in  gastric  cancer.  Consequent h\.  we  have  numerous  in- 
stances where  malignant  symptoms  have  existed  for  less 
than  2  months,  and  yet  the  resultant  tumors  were  definitely 
anchored  by  secondary  involvement  of  adjacent  struc- 
tures. On  the  other  hand,  certain  tumors  may  exist  (par- 
ticularly in  the  pyloric  region,  or  upon  the  lesser  cm'vature) 
for  as  long  as  nearly  I'^i  years,  and  upon  palpation  and  at 
laparotomy  be  shown  to  be  entirely  free.  Of  tumors  where 
the  evidently  mahgnant  disease  had  existed  for  from  6  to 
12  months,  but  22  per  cent,  were  mechanically  mobile.  In 
instances  where  a  long  precancerous  history  is  obtained,  not 
rarely  the  comphcations  occurring  during  that  period  early 
limit   mobihty  of  the  supervening  tumor.     This  is  very 


PHYSICAL   ABNORMALITIES  181 

likely  to  be  the  case  if  the  early  gastric  history  has  been  that 
which  clinically  we  recognize  as  peptic  ulcer. 

The  position  which  a  neoplasm  occupies  in  the  gastric  wall 
greatly  influences  its  freedom  of  movement.  Carcinomata 
in  the  pyloric  third  of  the  stomach  exhibit  the  greatest  de- 
gree of  possible  displacement.  Tumors  of  the  anterior  wall 
or  of  the  greater  curvature  long  remain  free.  Growths 
upon  the  lesser  curvature  proximal  to  the  antrum  remain 
relatively  freely  mobile,  but  on  account  of  their  tendency 
to  metastasis  to  the  pancreas,  liver  and  adjacent  thickly 
grouped  lymph  glands,  they  may  quite  early  become  only 
limitedly  movable.  Tumors  of  the  posterior  wall  early 
become  fixed  by  reason  of  extension  to  surrounding  organs 
(especially  to  the  pancreas).  The  anatomical  limitation 
of  movement  at  the  cardia  and  fundus  account  for  tumors 
in  such  locations  being  the  least  mobile  of  all  gastric 
neoplasms. 

Complications  may  limit  the  mohility  of  a  tumor  at  any 
stage  of  its  progress.  Such  limitations  may  occur  very 
quickly.  Acute  or  chronic  perforations,  contiguous  ex- 
tension to  adjacent  viscera,  perigastric  lymph-gland  in- 
volvement, inflammatory  adhesions  or  the  rapid  accumu- 
lation of  free  fluid  in  the  peritoneal  sac  may  immobilize  a 
gastric  cancer.  Occasionally,  such  complications  convey 
greater  mechanical  mobility — as,  for  example,  when  free 
fluid  ''floats  up"  a  tumor,  or  when  an  adhesion  to  the  bowel 
or  omentum  permits  the  dragging  about  of  a  stomach 
growth. 

The  degree  of  mobility  of  some  gastric  neoplasms  is  varied 
accordingly  as  palpation  is  carried  on  with  the  patient  in 
different  positions.  Not  infrequently  a  growth  which  was 
not  palpable  with  the  patient  in  the  dorsal  position,  or  was 
only  indefinitely  palpable  or  movable,  becomes  readily  rec- 


182  CANCER  OF  THE  STOMACH 

ognizable  if  he  is  placed  in  either  lateral  or  knee-chest 
posture.  Tumors  of  the  body  or  fundus  may  be  shown  to 
be  mobile  by  having  the  patient  sit  or  stand  after  the 
location  occupied  by  the  growth  in  the  dorsal  position  has 
been  previously  outlined.  Placing  the  subject  in  the  Tren- 
delenburg position  occasionally  causes  tumors  of  the  upper 
epigastrium  to  move  upward  beneath  the  liver,  sternum 
or  rib  margins  or  to  be  lost  through  the  change  of  position 
of  free  peritoneal  fluid.  - 

When  the  stomach  or  colon  is  distended  with  air  or  gas 
marked  alterations  in  the  location,  the  shape  or  size  of 
gastric  cancers  may  become  evident.  Upon  gastric  infla- 
tion we  have  seen  carcinomata  displaced  as  far  as  9  inches 
from  the  place  where  they  were  palpated  with  the  stomach 
empty.  Pyloric  tumors  may  travel  from  the  left,  upper 
quadrant  to  the  mid-epigastrium,  the  right  epigastrium, 
the  region  of  the  navel,  the  left  hypochondrium,  and  rarely 
to  the  suprapubic  region.  We  have  observed  one  male 
patient  in  whom  an  immense,  dilated  stomach  permitted  the 
pyloric  cancer  to  drop  into  the  pelvis  upon  gastric  inflation. 
In  female  subjects  with  low-lying  stomachs,  normally, 
the  pyloric  tumor  is  usually  displaced  to  a  lower  point 
upon  inflation  than  is  the  case  in  the  average  male  patient. 
Tumors  of  the  lesser  curvature,  fundus  or  greater  curvature 
are  often  displaced  as  much  as  5  inches  upon  gastric  in- 
flation. Not  infrequently  the  rotation  of  the  distended 
stomach  permits  the  ready  palpation  of  a  tumor  which  had 
before  been  indeflnitely  recognized.  While  gastric  inflation 
usually  increases  the  size  of  a  palpable  mass,  there  are  in- 
stances where  a  tumor  is  barely  felt  or  even  lost  altogether 
after  this  maneuver. 

Most  commonly,  air  inflation  of  the  colon  (through  a  rec- 
tal tube)_displaces  gastric  cancers  upward  or  to  the  right. 


PHYSICAL   ABNORMALITIES  183 

A  low-lying  .transverse  colon  adherent  to  an  involved 
omentum,  or  to  the  gastric  tumor  itself,  may  drag  down  the 
neoplasm  upon  colon  being  inflated.  Colon  distention 
may  push  up  under  the  edge  of  the  ribs  or  beneath  the 
margin  of  the  liver,  tumors  which  had  been  both  visible 
and  palpable. 

The  successive  inflation  of  the  stomach  and  the  colon  is 
an  extremely  valuable  procedure  in  the  differential  diagno- 
sis of  obscure  abdominal  neoplasms. 

The  thickness  of  the  abdominal  parieties  may  vary  the 
ease  with  which  gastric  tumors  are  palpable  to  such 
extent  that  one  may  or  may  not  be  in  doubt  regarding  the 
mobility  of  such. 

Respiratory  movements  displace  practically  all  tumors  of 
the  gastro-intestinal  system  lying  above  the  navel.  In- 
spiration usually  forces  downward,  or  downward  mesially 
or  latterly,  cancers  of  the  pyloric  third,  the  lesser  curvature, 
the  anterior  wall  or  the  greater  curvature  of  the  stomach. 
The  extent  of  the  displacement  rarely  exceeds  3  inches. 
Tumors  of  the  fundus,  high  lesser  curvature  or  the  cardiac 
region  may  become  palpable  following  deep  inspiration. 
Inspiration  not  infrequently  forces  the  stomach  forward 
when  the  patient  lies  in  the  dorsal  position,  so  that  a  tumor 
of  greater  extent  may  be  felt  at  the  end  of  deep  inspiration 
than  when  the  subject  is  in  expiration  or  breathing  quietly. 

If  at  the  end  of  inspiration  a  tumor  can  be  held  down  while 
expiration  takes  place,  the  possibility  of  adhesions  to  or 
contiguous  involvement  of  such  solid  organs  as  the  liver, 
spleen,  or  left  kidney  is  less  than  if  the  expiratory  move- 
ment carried  upward  the  palpable  epigastric  tumor.  Such 
diagnostic  maneuver  does  not  always  indicate  the  opera- 
bility  or  the  inoperability  of  a  gastric  cancer.  Extensive, 
deeply  lying  adhesions  (to  pancreas,  retroperitoneal  tissues, 


184  CANCER  OF  THE  STOMACH 

bowel)  or  widespread  invasion  of  the  lymphatic  system 
may  occur  wholly  irrespective  of  the  degree  of  mobility  of 
the  primar}^  focus  in  the  stomach. 

Gland  Involvement. — The  observation  that  enlargement 
is  taking  place  in  groups  of  surface  lymphatics  has  great 
value  in  indicating  methods  of  therapy.  ^Tiere  there  has 
been  malignant  invasion  of  superficial  lymphatics,  it  can 
hardly  be  expected  that  surgical  procedures  are  of  any 
permanent  worth,  excepting  in  rare  instances  where  opera- 
tive measures  are  carried  out  for  the  relief  of  mechanical 
obstruction.  The  enlargement  of  such  gland  groups  as 
those  lying  above  the  left  clavicle  (Virchow's  gland),  the 
inguinal  nodes,  about  the  navel  or  lying  in  the  cul-de-sac 
posterior  to  the  bladder,  clearly  indicates  that  the  disease 
has  been  scattered  far  beyond  its  source  of  origin  in  the 
stomach,  and  it  is  but  a  question  of  time  before  fatal 
termination  will  result.  Careful  palpation  should  be 
carried  on  in  a  systematic  manner  in  an  effort  to  recognize 
these  lymph-gland  metastases.  Sometimes  the  inguinal 
nodes  are  but  slightly  swollen.  They  may  be  as  large  as 
common  marbles.  They  are  usually  the  last  of  the  lymph- 
gland  chains  to  show  involvement  of  intra-abdominal  ma- 
lignant disease.  The  glands  are  as  a  rule  discrete.  They 
are  rarely  tender  to  the  touch,  and  we  have  never  seen  a 
case  where  infiltration  from  such  glands  occurred  in  the 
surrounding  or  adjacent  structures.  We  have  never  seen 
an  instance  of  ulceration  or  necrosis  in  malignant  involve- 
ment of  such  superficial  lymph  nodes.  Invasion  of  the 
lymph  tissue  in  the  neighborhood  of  the  navel  is  rather  rare. 
It  usually  occurs  when  there  has  been  quite  active  perito- 
neal involvement. 

"Blumer's  shelf  is  not  an  infrequent  site  for  the  loca- 
tion of  pelvic  metastasis  in  mahgnant  disease  of  the  stom- 


PHYSICAL   ABNORMALITIES  185 

ach.  Upon  rectal  examination  one  is  able  to  outline  a  small 
shelf-like  or  pouch-like  projection  posterior  to  the  bladder. 
In  a  normal  individual  this  is  free,  but  where  an  extensive 
carcinoma  has  involved  the  stomach  and  freely  metastasized, 
one  can  not  infrequently  delimit  at  the  tip  of  the  examining 
finger  one  or  several  discrete  nodules  lying  in  this  pouch. 
Metastases  to  this  location  seem  to  occur  with  more  fre- 
quency than  to  other  lymph-gland  areas.  This  is  probably 
due  to  the  fact  that  with  the  patient  in  an  erect  position 
cancer  cells  are  carried  into  the  pelvis  along  the  peritoneal 
surface  by  force  of  gravity.  There  may  be  some  other 
reason  why  there  is  an  apparent  predilection  for  gland 
invasion  at  this  point. 

We  have  never  seen  a  case,  where  enlarged  glands  were 
palpated  as  ''Blumer's  shelf,"  that  was  operable,  i.e.,  in 
the  sense  of  permanent  relief,  even  by  the  most  radical 
resection.  In  our  series  of  cases  metastasis  to  this  region 
was  noted  in  16  per  cent. 

Enlargement  of  the  supraclavicular  glands  might  logically 
be  considered  at  this  point.  We  noted  such  enlargement 
in  11.5  per  cent.  We  have  already  mentioned  why  it  is 
that  gland  metastases  from  cancers  in  the  stomach  occur 
with  rather  striking  frequency  above  the  left  clavicle.  We 
have  noted  but  a  few  instances  where  coincident  or  in- 
dependent enlargement  of  glands  in  the  right  supracla- 
vicular space  could  be  demonstrated.  We  have  never  seen 
an  instance  where  the  malignant  invasion  of  these  glands 
occurred  without  the  primary  focus  being  beyond  the  hope 
of  permanent  relief  by  surgical  measures. 

Another  evidence  of  extensive  gland  involvement  by 
cancer  is  shown  upon  palpation  by  the  presence  of  free 
peritoneal  fluid.  The  cancerous  intoxication  or  irritation 
usually  results  in  rather  rapid  accumulation  of  free  ab- 


186  CANCER  OF  THE  STOMACH 

dominal  fluid.  Palpation  frequently  enables  one  to  roughly 
estimate  the  volume  of  such  exudate  by  noting  alterations 
in  the  local  or  general  laxness  or  tension  of  the  abdominal 
wall.  The  character  of  the  abdominal  fluid  varies.  It  is 
usually  thin  enough  to  permit  of  its  rapidly  shifting  from 
one  part  of  the  abdominal  cavity  to  the  other .  Further 
considerations  of  abdominal  fluid  are  given  in  Chapter  VII. 

A  palpable  liver  may  result  from  secondary  involvement 
of  that  organ  through  the  lymph  stream  or  contiguous  in- 
volvement from  the  primary  tumor.  When  the  liver  can 
be  well  outlined  by  the  palpating  fingers,  either  along  its 
entire  lower  margin,  or  locally  at  any  point,  one  can  safely 
say  that  the  primary  growth  is  irremovable.  In  our  ex- 
perience the  liver  was  palpable  in  23  per  cent. 

Lymph  glands  about  the  pylorus  or  the  lesser  curvature 
can  occasionally  be  felt  where  the  disease  is  extensive, 
where  the  parietes  is  not  too  thick,  or  where  the  presence  of 
free  fluid  does  not  interfere  with  palpation.  In  certain  in- 
stances these  glands  may  be  largely  responsible  for  pyloric 
obstruction. 

Where  pyloric  obstruction  occurs  early,  while  the  peris- 
taltic activity  of  the  stomach  is  still  vigorous,  during 
palpation  the  stiffening  and  increased  tension  of  the  gastric 
wall  may  be  felt  beneath  the  palpating  hand. 

It  is  perhaps  important  here  to  emphasize  the  above 
seven  signs  of  inoperability  of  gastric  neoplasms.  They  are : 
evidence  of  gland  enlargement  above  the  left  clavicle,  Blu- 
mer's  rectal  shelf,  to  the  umbilicus,  local  or  general  increase 
in  size  of  the  liver,  presence  of  free  peritoneal  fluid,  enlarge- 
ment of  the  inguinal  lymph  nodes,  and  palpable  lymphatic 
metastases  about  the  pylorus  or  along  the  lesser  curvature. 

Even  if  the  primary  tumor  is  not  itself  large,  or  even 
though  it  may  be  freely  movable,  the  discovery  of  any  or 


PHYSICAL   ABNORMALITIES  187 

all  of  the  above  external  evidences  of  the  spread  of  the 
disease  seriously  limits  the  prognosis  from  the  various  types 
of  surgical  operation. 

In  all  these  instances  where  lymphatic  involvement  is 
determined  an  attempt  should  be  made  to  remove  one  of  the 
enlarged  nodes  for  the  purpose  of  microscopic  study. 
It  is  usually  quite  possible  to- remove  one  of  these  glands 
with  the  aid  of  a  simple  local  anesthetic  (ethyl  chlorid  or  a 
2  per  cent,  cocaine  solution).  Examination  of  the  tissue 
removed  may  be  rapidly  made  with  the  aid  of  an  apparatus 
for  cutting  frozen  sections.  These  can  be  readily  stained 
with  Unna's  polychrome  methylene  blue.  It  should  be  em- 
phasized here  that  the  judgment  of  an  expert  is  required 
in  many  instances  to  determine  the  histologic  changes  oc- 
curring in  these  removed  lymph  nodes.  Operative  proce- 
dures should  never  be  neglected  solely  upon  the  evidence 
furnished  by  the  examination  of  extirpated  glands. 

Percussion. — This  diagnostic  maneuver  is  of  but  limited 
value.  The  greatest  service  it  renders  is  in  the  determina- 
tion of  enlargements  of  solid  organs  (liver,  spleen),  the  dem- 
onstration of  the  amount  and  mobility  of  peritoneal  fluid, 
and  occasionally  in  enabling  one  to  form  an  approximate 
estimation  of  the  size  of  the  gastric  cancer.  Sometimes  it 
is  possible  to  outline  a  dilated  or  distended  stomach  by 
percussion.  When  such  gastric  limits  are  checked  by 
operative  procedure  or  a:;-ray  examination,  one  generally 
discovers  that  the  percussion  outlines  only  roughly  esti- 
mate the  actual  size  or  even  the  position  of  the  viscus. 

There  are  certain  cases  where  no  epigastric  tumor  can  be 
definitely  palpable,  and  yet  percussion  enables  one  to  de- 
limit areas  of  dulness  in  certain  parts  of  the  abdomen  where 
one  suspects  that  a  neoplasm  exists. 

Percussion  should  be  carried  on  with  the  use  of  both  light 


188  CANCER  OF  THE  STOMACH 

and  heavy  strokes.  Not  infrequently  where  hght  percussion 
demonstrates  tympany,  deeper  percussion  results  in  high- 
pitched  tones  that  suggest  airless  tissue  lying  below  a 
gas-filled  hollow  vise  us. 

In  cases  where  the  peritoneal  sac  is  not  too  greatly  dis- 
tended with  fluid,  one  can  delimit  areas  of  dulness  and 
tympany  that  frequently  change  their  outlines  upon  the 
subject's  assuming  various  positions. 

If  the  accumulation  of  fluid  is  great  and  the  gastro- 
intestinal tract  is  empty,  the  entire  abdomen  may  lack 
resonant  tones  upon  light  or  even  deep  tapping. 

Occasionally,  hollow  viscera  are  floated  upon  moderate 
accumulations  of  free  peritoneal  fluid.  As  a  result,  the 
major  portion  of  the  abdomen  may  be  tympanitic  to  per- 
cussion with  the  patient  in  the  dorsal  position.  In  such 
instances,  however,  it  is  extremely  uncommon  not  to  find 
dulness  in  the  flanks  or  in  the  dependent  portions  of  the 
abdomen  when  the  patient  sits  up,  stands  erect,  or  assumes 
the  knee-chest  posture. 

We  have  frequently  observed  an  interesting,  and  we 
believe  a  hitherto  undescribed,  percussion  sign  in  cases  where 
cancer  involves  the  fundus  or  the  anterior  waU  of  the  body 
of  the  stomach. 

WTien  the  patient  is  in  the  dorsal  position  percussion  of 
Traube's  space  is  not  uncommonly  dull  instead  of  normally 
tympanitic.  Examination  by  percussion  of  the  same  area 
at  the  end  of  deep  inspiration,  or  upon  the  patient  lying 
on  the  right  side,  or  standing,  sometimes  results  in  the  dis- 
appearance of  the  dull  tones  upon  the  percussion  of  Traube's 
space  and  the  appearance  of  characteristic  tympany. 
This  sign  we  have  observed  in  18  out  of  24  cases  of  carci- 
noma involving  the  superior  portion  of  the  stomach  where 
an  epigastric  tumor  could  not  be  palpated. 


PHYSICAL   ABNORMALITIES  189 

Auscultation  is  of  relatively  little  diagnostic  value  in 
cases  of  gastric  carcinoma. 

Occasionally  it  is  useful  to  prove  that  the  contents  of  the 
esophagus  pass  into  the  stomach  where  a  growth  is  known 
to  exist  in  the  region  of  the  cardia.  If  the  orifice  is  patent, 
auscultation  over  the  region  of  the  cardia,  anterior  or 
posterior,  enables  the  recognition  of  the  second  swallowing 
sound  when  swallowed  liquid  passes  from  the  esophagus  into 
the  stomach,  should  the  cardiac  orifice  be  patent.  If  the 
individual  is  obese,  or  the  cardia  be  moderately  closed 
(particularly  with  a  papillomatous  growth)  the  second 
swallowing  sound  is  usually  greatly  modified  or  entirely 
unrecognizable  upon  auscultation. 

Auscultation  over  the  epigastrium  proper  sometimes 
furnishes  an  index  of  the  peristaltic  activity  in  a  given 
stomach.  This  is  sometimes  of  value  in  determining 
stomach  outline  upon  inflation  of  the  viscus  with  air  through 
a  stomach  tube  or  the  patency  of  a  ring  cancer  of  the 
pylorus,  in  allowing  one  to  ascertain  the  degree  of  obstruc- 
tion by  listening  for  gurgling  sounds  caused  by  the  passage 
of  air  and  fluid. 

In  cases  where  an  extension  of  the  malignant  growth  to 
an  adjacent  loop  of  the  bowel  is  suspected,  with  greater 
or  less  obstruction  of  the  lumen  of  the  bowel,  auscultation 
sometimes  permits  us  to  state  whether  or  no  the  air  or 
liquid  has  passed  beyond  the  suspected  area  of  constriction. 

In  rare  instances,  auscultatory  evidences  of  the  patency 
of  a  gastro-enterostomy  stoma  are  established  by  listening 
over  the  region  of  the  artificial  opening,  or  over  the  bowel 
beyond. 

GASTROSCOPY 

During  the  last  3  decades  a  number  of  men  have  given 
their  attention  to  the  design  of  a  practical  gastroscope, 


190 


CANCER   or   THE    STOMACH 


among  whom  should  be  mentioned  Mikulicz,  Rosenheim, 
Kausch,  Forametti,  Jackson,  Kuttner,  Kelling,  Eisner, 
Janeway  and  Hall. 

As  the  result  of  the  work  of  these  men  a  number  of  in- 
struments have  been  made.  These  have  met  with  more  or 
less  success. 

Sussmann  Gastroscope. — Some  5  years  ago.  Dr.  Martin 
Sussmann  of  Berlin  constructed  a  crude  model  of  a  flexible 
gastroscope  which  seemed  to  fulfill  the  requirements  in  a 


Fig.  47. — Sussmann  Gastroscope. 


theoretical  way,  but  he  experienced  difl&culty  in  having 
the  optical  system  and  mechanical  parts  made.  After 
4  years  of  experimenting,  he  finally  succeeded  in  perfecting 
the  instrument  as  shown  in  the  illustrations  (Fig.  47). 

Contrary  to  the  impression  one  might  first  have  from 
these  illustrations,  the  instrument  is  extremely  simple  in 
manipulation.  The  appliance  consists  primarily  of  2  parts, 
the  non-flexible  part  A  and  the  flexible  part  B.  The  total 
length  from  eyepiece  to  the  lens  at  the  distal  end  is  74  cm. 


PHYSICAL   .iJBXOEMALITIES  191 

of  which  part  .-i,  non-flexible,  is  24  cm.  and  part  B  50  cm. 
The  diameter  is  12}4  mm. 

The  non-flexible  part  A  is  set  at  an  angle  of  150°  to  part 
B,  and  in  spite  of  this  angle  and  the  comparative  great 
length  of  the  instrument,  a  clear  view  can  be  had  of  the 
walls  of  the  stomach  when  distended  with  air,  due  to  the 
ingenious  systems  of  lenses  which  have  been  adopted.  On 
part  A  is  mounted  the  ocular  (9).  The  turning  device 
with  indicator  (3)  for  revolving  the  objective  at  the  distal 
end  of  part  B,  lever  (2)  for  placing  the  instrument  in  a  flex- 
ible condition,  tension  wheel  (1)  for  replacing  the  instru- 
ment in  a  rigid  position,  connection  for  compressed  air 
tubing  (6),  with  needle  air  control  valve  (7)  and  a  hook  or 
finger  rest  (8).  Part  B  is  covered  with  a  pure  gum  tube. 
At  the  distal  end  of  the  instrument  is  located  the  objective. 
Mounted  on  each  side  of  the  objective  is  a  small  flat  tung- 
sten filament  electric  bulb,  the  objective  and  bulb  being 
covered  by  a  hood  or  protector  which  is  made  of  glass  and 
metal,  preventing  the  entrance  of  moisture  and  mucus, 
which  might  otherwise  cause  difficulty  in  the  illuminating 
on  account  of  short-circuiting  of  the  current.  In  earlier 
forms  of  gastroscopes  this  turning  feature  offered  quite  an 
objection,  in  that  the  entire  tube  was  turned,  making  the 
procedure  a  painful  one  to  the  patient. 

Fig,  47  shows  the  gastroscope  in  a  flexible  position,  and 
also  in  a  rigid  position,  as  set  for  the  purpose  of  inspection. 
Fig.  47,  3  shows  the  method  of  introduction.  Change 
from  rigid  to  flexible  is  easily  accomphshed  by  simply 
throwing  back  lever  2  from  position  A  to  B  and  giving 
it  a  sHght  amount  of  pressure. 

The  system  of  lenses  employed  deserves  special  mention, 
from  the  fact  that  they  are  unusual  in  many  respects.  It 
is  generally  considered  that  in  passing  the  instrument  the 


192  CANCER  OF  THE  STOMACH 

shortest  distance,  from  objective  to  the  posterior  wall  or 
entrance  to  the  cardia  is  2  mm.  and  that  the  average  dis- 
tance in  a  well-inflated  stomach  is  7  cm.  from  the  objective 
to  the  part  under  inspection.  The  lens  system,  however, 
is  universal  in  so  far  as  an  object  will  present  a  sharp,  clear 
view,  whether  within  2  mm.  of  the  lens  or  at  a  distance  of 
7  mm.  The  eyepiece  (9)  may  be  adjusted  so  as  to  accom- 
modate itself  to  the  lens  system.  The  range  of  the  field 
under  observation  at  one  time  is  sufficient  so  that  an  area 
measuring  6  cm.  across  may  be  observed  without  any  read- 
justment of  the  instrument.  This  makes  it  possible  to 
observe  the  entire  wall  of  the  stomach,  since  the  lens  sys- 
tem can  be  turned  so  as  to  describe  a  complete  circle  and 
the  instrument  may  be  moved  downward  to  any  point. 

The  inventor  claims  that  this  instrument  can  be  intro- 
duced without  difficulty  in  every  case  where  it  is  possible  to 
introduce  a  stomach  tube,  and  that  the  introduction  is 
easier  than  with  a  straight,  non-flexible  instrument. 

Since  the  above  illustrations  were  made,  the  inventor  has 
added  an  important  improvement  to  the  gastroscope,  in 
the  shape  of  a  second  ocular,  which  permits  of  two  persons 
observing  the  conditions  of  the  stomach  at  the  same  time. 

There  is  an  air  inlet  with  automatic  valve.  To  this  is 
connected  a  double  balloon  or  foot  bellows  for  the  inflation 
of  the  stomach.  In  order  to  be  absolutely  sure  of  just  how 
much  pressure  one  is  using,  a  manometer  may  be  used  in 
connection. 


CHAPTER  Y 
EXAMINATION    OF    GASTRO -INTESTINAL   FUNCTION 

This  concerns  itself  chiefly  with  analysis  of  gastric  con- 
tents and  feces.  Of  minor  value  are  examination  of  vomitiis, 
determination  of  the  position,  size  and  shape  of  the  stomach 
and  demonstration  of  the  patency,  mobility  and  situation 
of  the  small  and  large  bowels. 

(A)  TEST-MEAL   EXAMINATION  OF  GASTRIC  FUNCTION 

In  well-established  cancer  of  the  stomach,  there  is  no 
method  of  chnical  investigation  which  fields  more  infor- 
mation of  worth  than  does  properly  appUed  study  of  certain 
features  of  gastric  function.  There  are  few  chnical  methods 
■ — and  certainly  no  chnical  laboratory  procedure — which 
enable  one  to  estimate  the  status  of  a  given  case  of  gastric 
cancer  so  quickly,  accurately  and  inexpensively  as  does  in- 
telligent scrutiny  of  test-meal  data.  There  is  no  disease  of 
the  stomach,  per  se,  which  returns  gastric-extract  analyses 
so  characteristic  as  those  exhibited  in  instances  of  what  is 
chnically  advanced  gastric  cancer.  In  cases  where  dubious 
information  is  furnished  by  test-meal  analyses,  it  can  be 
demonstrated  to  be  a  fact  that  other  clinical  and  laboratory 
aids  are  rarely  conclusive  and  that  in  these  cases  final  opin- 
ion generally  rests  upon  exploratory  laparotomy  and  the 
report  of  the  ceUular  pathologist.  These  statements  are 
based  upon  the  author's  personal  analysis  of  7,192  gastric 
extracts. 

Our  series  of  cases  gives  us  701  instances  of  proved  gastric 
cancer  in  which  test-meal  examination  of  stomach  function 
was  carried  out.     It  is  our  purpose  to  consider  this  phase  of 

13  193 


194  CANCER  OF  THE  STOMACH 

clinical  examination  in  the  light  of  the  facts  returned  by 
such  analyses.  It  has  been  our  endeavor  to  discriminate 
between  essentials  and  non-essentials. 

Much  opprobrium  has  been  attached  to  test-meal  work 
during  recent  years.  This  has  resulted  largely  from  the 
clinical  laboratory  being  expected  to  do  all  the  work  rela- 
tive to  making  a  diagnosis,  and  often  from  a  few  cubic  centi- 
meters of  material  brought  or  sent  to  it;  from  certain  labo- 
ratory men  failing  to  distinguish  useful,  practical,  clinical 
tests  from  those  chemically  fascinating,  but  often  entirely 
of  an  experimental  nature;  from  the  eager  pursuit  of 
"specific"  tests  for  each  disease  or  every  symptom  of  it, 
and  from  the  failure  of  patient,  analyst,  pathologist  and 
surgeon  to  ''get  together"  in  an  attempt  to  establish  facts 
of  worth  from  the  mass  of  information  collected  inde- 
pendently. 

From  rather  more  than  a  casual  acquaintance  with  the. 
subject  our  records  indicate  that  examination  of  gastric 
function  has  to  do  mainly  with  the  investigation  of  (1)  the 
emptying  power  of  the  stomach;  (2)  the  chemical  analysis 
of  test-meal  extracts  or  vomitus;  and  (3)  the  microscopic 
study  of  gastric  contents  or  vomitus. 

INVESTIGATION  OF  GASTRIC  EMPTYING  POWER 

Scarcely  a  year  passes  without  some  ''new"  method  for 
estimating  gastric  emptying  power  being  exploited.  The 
very  fact  that  clinicians  of  reputedly  large  experience  fre- 
quently put  forth  these  procedures  would  appear  to  indi- 
cate either  that  there  is  no  satisfactory  method  of  de- 
termining the  time  of  the  stomach's  emptying  or  that  the 
emptying-rate  of  the  so-called  "normal"  stomach  is  un- 
settled. It  is  a  waste  of  space  and  energy  to  catalogue  the 
various  novel  and  often  amusingly  ingenious  "  mo  tor- tests  " 


EXAZMIXATIOX    OF    GASTRO-IXTESTIXAL    FUXCTIOX       195 

that  have  been  described.  TTe  have  found  the  following 
procedure  useful.  It  has  limitations.  A  not  altogether 
unimportant  feature  of  the  information  returned  bj'  this 
motor-meal,  in  our  series,  Ues  in  its  having  been  adminis- 
tered to  a  large  number  of  patients  whose  ailments  were 
subsequently  determined  at  laparotomy. 

(a)  Physiologic  Method  of  Estimating  Gastric  Emptying 
Power. — Its  object  is  to  prove  whether  food  can  pass  into 
or  out  of  the  stomach.  The  contraindications  are  few: 
recent  severe  hemorrhage,  clinical  evidences  of  perforation, 
coma,  extreme  asthenia,  severe  cardio-renal  distui'bances 
or  mental  upsets. 

Method. — The  patient's  stomach  should  be  washed  free 
from  whatever  material  it  contains.  Following  the  lavage 
(pro'\T.ded  the  chnical  histor}'  of  marked  stenoses  at  the 
orifices  has  not  been  obtained)  2  ounces  of  castor  oil  are  ad- 
ministered thi'ough  the  stomach  tube  or  per  or  am.  Three 
hours  later  the  patient  is  allowed  to  eat  a  moderate-size 
meal  of  mixed  food,  in  the  manner  that  he  ordinarily  fol- 
lows. This  meal  contains  anaong  other  ingredients,  at 
least  50  grams  of  cold  meat,  2  leaves  of  head  lettuce,  and  20 
raw  raisins.  Instructions  are  sometimes  needed  to  insure 
the  patient's  swallowing  the  skins  of  the  raisins.  It  is 
important  that  they  should  be  eaten.  Beverages  are 
allowed,  preferabh'  water,  milk,  or  weak  tea.  This  meal 
has  the  advantages  of  being  readily  available,  palatable 
and  of  sufficient  bulk.  The  last  consideration  is  of  essential 
value  in  any  motor-meal.  It  is  impossible  to  estabhsh 
evidence  of  the  anatomic  condition  of  the  stomach's  orifices 
by  motor-meals  of  the  baby  pap  tx^Q.  An  interval  of 
from  8  to  12  hom's  is  permitted  to  elapse  before  a  stomach 
tube  is  passed  and  attempts  at  the  recovery  of  remains  of 
the  motor  meal  are  made.     Experience  has  taught  us  that 


196  CANCER  OF  THE  STOMACH 

food  remnants  present  constantly  in  a  stomach  after  8 
hours  generally  indicate  some  mechanical  hindrance  to  their 
free  exit  from  the  viscus.  It  is  not  uncommon  in  healthy 
individuals  to  demonstrate  the  presence  of  food  in  the  stom- 
ach after  4  to  6  hours,  i.e.,  the  common  time  hmit  for 
estimation  of  gastric  emptying  power.  In  many  instances 
of.  pyloric  spasm,  associated  with  peptic  ulcer,  disease  of  the 


Fig.  48. — Motor-meal  and  lavage  tube  showing  distal  end,  markings  on 
tube  and  the  aluminum  mid-piece. — (Author.) 

gall-bladder,  the  appendix,  etc.,  intermittent  (and  some- 
times marked)  6-  to  8-hour  residues  may  be  removed  from 
the  stomach.  In  pronounced  atony,  rather  more  than  4 
per  cent,  of  cases  exhibit  food  retained  longer  than  6  hours. 
For  the  purpose  of  readily  removing  gastric  contents  we 
some  time  since  constructed  the  stomach  tube  illustrated 
by  Figs.  48  and  49. 


Ex,\:\nxATiox  of  gasteo-ixtestixal  FrxcTiox    197 

Motor-meal  and  Lavage  Tube. — Stomach  tubes,  as  ordi- 
narily made,  seem  to  have  the  following  faults:  (1)  the 
inferior  rubber  in  their  construction,  which  prevents  ster- 
ilization by  boiling  (the  only  efficient  method);  (2)  small 
lumina,  which  frequently  render  unsatisfactory  the  aspira- 
tion or  expression  of  motor-meals  or  poorly  ch^'mified 
test-breakfasts;  (3)  improperlj'-  placed,  too  few  or  too  small 
fenestra  at  their  distal  ends;  (4)  the  incorporation  into  the 
tubes  of  '^ aspirating  bulbs  "^  of  questionable  service,  which 
are  difficult  to  keep  clean.  In  an  effort  to  remedy  some  of 
these  defects,  we  have  had  constructed  tubes  of  the  t^^e 
to  be   described.     They  have   given  greater  satisfaction 


Fig.  49. — Motor-meal  and  lavage  tube  showmg  openiags  in  distal  end. — 

(^Author.) 

than  any  other  form  in  the  last  1,800  cases  examined  in 
which  test-meal  examinations  were  made. 

The  tube  is  constructed  of  the  best  quality  of  red  rubber. 
The  waU  is  2  mm.  thick  and  the  lumen  has  a  diameter  of  9 
mm.  The  tube  is  made  in  two  sections,  distal  and  proximal, 
connected  by  a  thin,  but  strong,  aluminum  mid-piece. 

The  distal  segment  of  the  tube  is  90  cm.  long.  It  has  a 
distal  opening  of  1  cm.  diameter.  Beginning  1  cm.  from 
this  tip  is  a  lateral  fenestrum  '^Tig.  49)  of  elUpsoid  form,  2 
cm.  long  and  1  cm.  wide.  On  the  opposite  lateral  surface 
to  this  is  a  second  similar  lateral  fenestrum,  which  begins 
3  cm.  from  the  tip  of  the  tube.  The  fenestrum  is  placed  at 
this  point,  not  only  to  permit  free  siphonage  of  gastric 
contents,  but  also  to  facilitate  the  introduction  of  the  tube. 


198  CANCER   OF   THE    STOMACH 

Its  location,  3  cm.  from  the  tip  of  the  tube,  is  the  average 
distance  in  different  individuals  from  the  pharyngeal  dip 
of  the  tongue  to  the  introitus  oesophagi.  When  the  tip  of 
the  tube  enters  the  pharynx,  with  the  second  lateral  fenes- 
trum  toward  the  tongue,  the  subject's  swallowing  motions 
promptly  bend  the  tube  at  this  fenestrum  and  the  tip  glides 
readily  into  the  esophagus.  Using  a  tube  with  a  distal  end 
of  this  type,  we  have  not  entered  the  larynx  more  than  a 
dozen  times  in  our  last  5,000  cases.  Eight  centimeters  from 
the  tip  of  the  tube  are  placed  three  round  fenestra,  of  a  diam- 
eter of  2  mm.  They  pierce  the  tube  at  the  same  level.  This 
distal  Segment  of  the  tube,  beginning  10  cm.  from  its  tip,  is 
marked  off  by  encircling  black  lines  (Fig.  48),  every  5  cm. 
for  a  distance  of  55  cm.  from  the  distal  end.  These  mark- 
ings permit  of  fairly  accurate  location  of  obstructions  in  the 
esophagus.  The  tube,  in  such  instances,  acts  as  a  hollow 
sound  through  which  the  contents  of  esophageal  saccula- 
tions and  the  like  may  be  readily  secured. 

The  connecting  aluminum  mid-piece  is  5  cm.  long,  with  a 
wall  1  mm.  thick  and  a  lumen  of  1  cm.  diameter.  It  is 
sUghtly  roughened  and  fits  snugly  into  the  rubber  parts. 
It  is  non-rusting. 

The  proximal  end  of  the  tube  is  60  cm.  long.  It  may  be 
replaced,  when  necessary,  by  an  aspiration  bulb  which  fits 
onto  the  metal  mid-piece. 

These  tubes  appear  to  have  many  advantages.  They 
are  durable;  they  may  be  boiled  for  months  and  still  retain 
their  form.  The  lumen  is  large  enough  to  permit  free  ex- 
pression or  aspiration  of  retention  contents  after  the  ad- 
ministration of  a  motor  test-meal.  The  distal  fenestra  are 
so  placed  as  to  permit  the  easy  passage  of  the  tube  and  the 
rapid  siphonage  or  aspiration  of  gastric  contents.  Free 
lavage  is  readily  carried  on,  either  for  the  purpose  of  de- 


EXAMINATION    OF    GASTRO-INTESTINAL   FUNCTION      199 

termining  retention  (as  in  hour-glass  stomach)  or  for  thera- 
peutic effect.  The  tube  acts  as  a  safe  and  convenient 
esophageal  sound.  The  aluminum  mid-piece  replaces  easily 
broken  glass  connections.  It  enables  one  rapidly  to  con- 
vert the  straight  siphon  or  lavage  tube  into  one  of  bulb 
type  for  the  purpose  of  inflating  the  stomach  with  air  or 
when  expression  of  gastric  contents  proves  difficult. 

In  the  passing  of  a  stomach  tube,  we  find  it  convenient  to 
seat  the  subject  upon  a  straight-backed  chair.  All  cloth- 
ing to  the  waist  is  removed,  except  an  undergarment. 
The  patient  places  his  hands  flat,  across  the  region  of  the 
navel.  The  head  should  be  tilted  slightly  forward.  This 
widens  the  introitus  cesophagi.  Appropriate  rubber  and 
linen  covers  protect  the  patient.  It  is  rarely  necessary  to 
hold  the  subject's  head,  etc.  After  boiling,  the  stomach 
tube  is  kept  until  needed  in  a  bowl  of  cracked  ice.  With 
the  patient  prepared,  the  end  of  the  cold  tube  is  rapidly 
passed  to  the  pharynx,  and  as  the  patient  swallows,  it  is 
advanced  boldly  and  rapidly  into  the  esophagus;  then 
passed  quickly,  but  carefully,  into  the  stomach.  Cough- 
ing, cyanosis  and  pain  promptly  develop  if  the  tube  has 
entered  the  larynx.  When  the  tube  reaches  the  stomach 
(recognized  by  gas,  or  contents  coming  from  the  tube  or 
by  the  feeling  of  its  passing  the  cardia)  the  patient  is  sharply 
commanded  to  press  his  hands  upon  his  belly  and  to  bend 
quickly  forward.  The  gastric  extracts  usually  spurt  from 
the  free  end  of  the  tube  promptly.  If  none  appear,  the  tube 
may  be  successively  advanced  and  retracted  cautiously, 
the  patient  instructed  to  cough,  or  an  aspirating  bulb 
used.  We  have  rarely  found  it  necessary  to  resort  to  such 
bulb.  Sometimes  the  gastric  contents  are  very  thick  or 
made  up  of  large  pieces  of  food.  In  this  event  one  may 
have  to  dilute  such  or  gradually  wash  the  material  out. 


200  CANCER  OF  THE  STOMACH 

Every  attempt  should  be  made  to  secure  contents  with- 
out resorting  to  this  procedure,  because  analysis  of 
the  material  removed  from  a  ^'fasting  stomach"  returns 
most  useful  information  (particularly  upon  microscopic 
examination) . 

Frequency  of  Gastric  Retention  in  Cancer  of  the  Stomach. — 
Some  degree  of  12-hour  retention  was  demonstrated  in 
483  cases  (69  per  cent.)  in  our  series  of  701  instances  where 
test-meal  data  are  available.  Frequently  the  amount  varied 
considerably  upon  repeated  examinations,  but  there  were 
but  20  per  cent,  of  cases  where  the  neoplasm  was  located 
at  the  antrum  or  distal  to  it  where  some  trace  of  food  re- 
tained for  from  8  to  12  hours  could  not  be  persistently 
demonstrated. 

THE  MACROSCOPIC  STUDY  OF  RETENTION  EXTRACTS  IN 
GASTRIC  CANCER 

If  the  pylorus  is  patent  the  wash-water  may  return  clear. 
This  is  especially  the  case  where  so-called  scirrhus  or  colloid 
cancers  are  present.  Fully  95  per  cent,  of  all  gastric  cancers 
contain  areas  where  cell-arrangement  is  of  the  medullary 
type.  It  follows,  consequently,  that  the  wash-water  is 
frequently  turbid  or  tinged  with  blood. 

Where  retention  exists  from  a  few  cubic  centimeters  to 
more  than  a  liter  of  more  or  less  altered  test-food  may  be 
removed.  Not  rarely,  large  pieces  of  partly  digested  mate- 
rial, intermixed  with  mucus,  together  with  puree-like  fluid 
are  secured. 

Color. — Traumatic  blood  was  noted  in  nearly  47  per  cent, 
of  223  consecutive  cases  in  our  series.  Bile  coloring  was 
observed  in  56  instances  (8  per  cent.).  It  commonly  oc- 
curred where  a  tough  fibrous  cancer  held  partly  open  the 
pylorus.     Classic  coffee-colored  or  dark  brown  extracts  were 


EXAMINATION    OF   G ASTRO-INTESTINAL   FUNCTION     201 

noted  in  149  cases  (21.3  per  cent.).  Such  growths  were 
inoperable  in  more  than  97  per  cent.  The  color  of  gastric 
contents  is  quite  as  apt  to  be  tan  or  brownish  in  non- 
malignant  stenoses  as  in  cancer.  Occasionally,  almost 
black  extracts  are  removed.  Such  are  often  due  to  dis- 
integrated blood  or  necrotic  tissue  or  medicines  (bismuth, 
iron  preparations). 

Odor. — In  more  than  80  per  cent,  of  our  cases,  acrid, 
rancid  odors  were  recorded.  They  are  usually  produced 
by  volatile,  organic  acids.  Such  odors  are  almost  pathog- 
nomonic of  malignancy  when  associated  with  12-hour  food 
retention.  Putrefactive  odors,  sometimes  nauseatingly 
penetrating,  may  be  encountered  from  sloughing  of  cancer 
tissue,  deterioration  of  blood,  perforation,  or  fistula  to 
adjacent  viscera. 

Mucus. — An  excess  is  observed  in  more  than  2  out  of  5 
instances  of  malignant  gastric  retention.  It  is  generally 
in  tough,  gelatinous  strings  or  ropes,  more  or  less  intimately 
mixed  with  food,  or  the  products  of  cancer  growth. 

Chymification  of  Test-food. — Where  peristalsis  is  below 
the  normal  strength  or  frequency,  free  hydrochloric  acidity 
low,  the  test-food  poorly  masticated  and  retention  pro- 
nounced, chymification  is  greatly  diminished.  Commonly, 
test-food  eaten  12  hours  previously  is  little  altered,  par- 
ticularly meat,  lettuce  or  raisin  skins. 

Acidity  of  "Fasting  Stomach"  Extracts. — Methods. — 
For  practical  clinical  use  sufficiently  accurate  relative  re- 
sults are  obtained  by  the  Toepfer  technique  of  determining 
acidity.  The  gastric  extracts  should  be  filtered,  if  quantity 
permits.  If  analyzed  unfiltered,  the  readings  are  apt  to  be 
higher  than  where  filtered  extracts  are  examined.  Other 
errors  may  occur. 


202  CANCER    OF   THE    STOMACH 

"Free  Hydrochloric^^  Acidity. — There  is  no  absolutely 
reliable  waj^  of  estimating  such  in  retention  contents,  be- 
cause, as  Schryver  and  Singer  have  emphasized,  hydro- 
chlorids  of  amino-acids  (end-digestion  products)  act  as 
acids,  and  organic  acids  (lactic,  butyric  and  acetic)  like- 
wise affect  such  indicators  as  dimethylamidoazohenzol  and 
GUnzberg's  reagent  (phloroglucin-vanillin  solution).  For 
comparative  work,  however,  it  appears  useful  to  estimate 
free  hydrochloric  acidity  with  dimethyl  as  an  indicator. 

Method. — Ten  cc.  of  gastric  filtrate  are  placed  in  a 
white  porcelain  evaporating  dish.  To  it  are  added  2  drops 
of  0.5  per  cent,  solution  of  dimethylamidoazobenzol 
in  95  per  cent,  alcohol.  If  free  hydrochloric  acid  is  pres- 
ent the  mixture  assumes  a  magenta  red.  The  acidity  is 
neutrahzed  by  slowly  adding  from  a  burette  n/10  solution  of 
sodium  hydroxide.  The  end  point  is  reached  when  the 
mixture  in  the  evaporating  dish  becomes  lemon  yellow  in 
color.  The  number  of  cubic  centimeters  or  parts  thereof 
required  to  bring  about  this  color  change  is  read  from  the 
burette.  This  figure  multiplied  by  10  gives  the  acidity 
per  hundred  parts.  If  the  acidity  per  cent,  is  desired, 
multiply  the  resultant  figure  by  0.00365. 

Degree  of  Free  Hydrochloric  Acidity  in  Retention  Contents. 
— In  319  cases  (66  per  cent.)  no  free  hydrochloric  acid  could 
be  detected  by  dimethyl  in  the  extracts  from  fasting  stom- 
achs. In  the  remaining  164  instances,  free  hydrochloric 
acid  ranged  from  2  to  70.  The  average  was  26.6.  In 
other  words,  practically  1  out  of  every  3  cases  of  gastric 
cancer  with  retention  of  food  have  free  hydrochloric  acid 
above  an  average  of  26,  in  the  fasting  stomach  contents. 

Total  Acidity. — This  is  a  term  of  but  relative  worth.  Its 
physiologic  significance  is  open  to  question.  CHnically, 
high  total  acidity  is  not  rarely  associated  with  abdominal 
discomfort,  nausea,  pyrosis  and  eructations.     Not  a  small 


EXAMINATION    OF   GASTRO-INTESTINAL   FUNCTION     203 

part   of  this  discomfort  would  appear  to  be   due  to   the 
presence  of  organic  acids  in  stagnant,  gastric  contents. 

Method  of  Determining  Total  Acidity. — Ten  cubic  centi- 
meters of  gastric  filtrate  are  placed  in  a  white  enamel 
evaporating  dish.  Two  drops  of  a  1  per  cent,  alcoholic 
solution  of  phenolphthalein  are  added.  There  is  usually 
no  color  change  unless  the  total  acidity  is  very  low  or  the 
extract  alkaline,  n/10  sodium  hydrate  solution  is  added 
to  the  mixture  from  a  burette.  "V\Tien  the  acidity  has 
been  neutrahzed  by  the  soda,  the  contents  of  the  evapo- 
rating dish  take  on  a  pinkish-red  hue.  The  degree  of 
acidity  is  computed  as  in  the  case  of  estimating  free 
hydrochloric.  Total  acidity  includes  free  hydrochloric, 
combined  hydrochloric,  organic  acids  and  acid  salts. 

Degree  of  Total  Acidity  in  Retention  Contents  in  Gastric 
Cancer. — In  none  of  the  483  cases  in  which  8-  to  12-hour 
food  retention  was  demonstrated  was  total  acidity  0.  The 
average  total  acidity  was  40.3.  The  minimum  was  4;  the 
maximum  132. 

"Combined"  acidity  as  estimated  by  using  sodium  aliza- 
rin solution  as  an  indicator  is  a  finding  of  dubious  value. 

Method. — Ten  cubic  centimeters  of  gastric  filtrate  are 
placed  in  a  white  porcelain  evaporating  dish.  To  this  are 
added  2  drops  of  sodium  alizarin  solution.  The  mixture 
is  titrated  against  n/10  sodium  hydroxide  solution  until 
the  contents  turn  violet.  Quantitatively,  the  estimation 
is  made  as  in  the  determination  of  free  hydrochloric. 

Degree  of  "Combined"  Acidity  in  Retention  Contents  of 
Gastric  Cancer. — Of  the  483  cases  in  this  series,  combined 
acidity  was  never  below  1.5.  The  average  was  16.5.  The 
minimum  was  1.5,  and  the  maximum  126. 

Acid  Salts. — Schryver  and  Singer  (loc.  cit.)  have  pointed 
out  in  their  admirable  critique  of  the  methods  employed  in 
gastric  analysis,  that  in  malignant  tumors  affecting  the 
pyloric  region  of  the  stomach,  the  amount  of  secreted  chlo- 


204  CANCER  OF  THE  STOMACH 

ride  is  generally  increased.  Our  483  observations  above 
detailed  upon  the  relation  of  total,  combined  and  free  hy- 
drochloric acidity  would  appear  to  add,  indirectly,  certain 
clinical  corroboration  of  this  fact. 

Lactic  Acid. — Tests  for  this  and  other  organic  acids  are 
more  commonly  positive  in  retention  contents  than  in  gas- 
tric extracts  where  there  has  been  no  evidence  of  pronounced 
stagnation. 

Method. — Six  drops  solution  of  liquor  ferri  sesqui- 
chlorati  are  added  to  3  drops  of  95  per  cent,  carbolic  acid. 
The  resultant  mixture  is  diluted  in  distilled  water  until 
it  assumes  a  lively  amethyst  blue.  To  this  last  solution 
are  then  added  from  5  to  10  drops  of  gastric  filtrate.  If 
lactic  acid  is  present  the  amethyst  blue  color  is  discharged 
upon  the  addition  of  the  gastric  filtrate  and  a  canary-yellow 
color  is  seen. 

Frequently  gastric  contents  which  have  been  extracted 
with  ether,  according  to  the  method  of  Strauss,  are  em- 
ployed in  the  above  outlined  test  in  place  of  the  unex- 
tracted  gastric  contents. 

By  the  adoption  of  this  modification  of  the  test  a  higher 
percentage  of  positives  is  returned  in  gastric  cancer  than 
where  the  original  procedure  was  employed. 

In  our  series  of  retention  contents  lactic  acid  was  dem- 
onstrated in  66.8  per  cent.  In  instances  where  lactic  acid 
was  demonstrated  95  per  cent,  were  inoperable  carcinomata. 
Of  this  number  58  per  cent,  had  no  precarcinomatous 
history  of  dyspepsia.  In  the  cases  where  there  had  been 
precarcinomatous  history  of  indigestion,  the  antecedent 
indigestion  had  been  of  the  type  clinically  peptic  ulcer  in 
only  42  per  cent. 

Altered  or  "Occult"  Blood. — Inasmuch  as  in  9  out  of  10 
instances  of  carcinoma  of  the  stomach  tumor  areas  are  shown 
which  pathologically  contain  tissue  of  the  medullary  type, 


EXAMINATION    OF   GASTRO-INTESTINAL   FUNCTION     205 

it  is  to  be  expected  that  from  time  to  time,  or  constantly,  a 
certain  amount  of  seepage  of  blood  will  occur.  As  we 
have  already  pointed  out  this  can  often  be  recognized  in  the 
wash-water,  particularly  after  vigorous  manipulation  of  the 
stomach  tube.  Where  the  hemorrhage  has  been  moder- 
ately profuse,  the  gastric  contents  range  in  color  from  light 
tan  to  dark  brown  or  almost  black.  In  the  majority  of 
instances  it  is  not  necessary  to  test  retention  contents  for 
blood  chemically.  Sometimes,  however,  the  administra- 
tion of  blood-building  or  styptic  medicines  (iron,  bismuth, 
tannic  acid,  etc.)  imparts  a  color  suspicious  of  blood  to  the 
gastric  contents.  Certain  forms  of  food  may  also  bring 
about  such  a  change  (red  wines,  soups,  meats,  chocolate, 
grape  juice,  etc.).  It  is,  therefore,  interesting  in  such  an 
event  to  definitely  prove  whether  or  no  the  color  is  due  to 
blood.  Of  course,  it  should  be  recognized  that  the  result- 
ant positive  test  may  come  not  from  the  bleeding  of  can- 
cerous tissue,  but  from  the  presence  in  retention  contents 
of  substances  derived  from  food  or  medicine. 

Method. — Many  tests  have  been  suggested.  If  properly 
controlled  the  majority  of  them  have  a  certain  place  clin- 
ically. The  most  common  ingredients  used  in  the  "occult" 
blood  test  are  phenolphthalein  (Boas)  guaiac,  benzidin  or 
orthotoluidin  (Ruttan  and  Hardisty). 

The  most  reliable  tests  for  the  proof  of  blood,  from  a 
purely  chemical  standpoint,  are  the  spectroscopic  test  or 
the  demonstration  of  hemin  crystals. 

The  tests  depending  upon  color  change  of  fluids  are, 
however,  more  convenient  of  application  than  are  those 
which  require  elaborate  apparatus  or  demand  more  or  less 
expert  knowledge  of  crystallography. 

Benzidin  Test. — Clinically  we  have  found  that  the  altered 
blood  test  performed  with  the  use  of  powdered  benzidin 


206  CANCER  OF  THE  STOMACH 

(pinkish-gray  powder)  is  quite  satisfactory.  We  have 
preferred  benzidin  to  guaiac  because  we  have  found  that 
positive  tests  to  it  are  returned  less  frequently  from  food 
than  in  the  event  where  guaiac  is  used.  Our  method  of  per- 
forming this  test  is  as  follows: 

Method. — To  5  cc.  of  gastric  extracts  are  added  5  drops 
of  glacial  acetic  acid.  This  forms  an  acid  hematin  if  blood 
be  present.  This  acid  hematin  is  then  extracted  by  the 
addition  of  5  cc.  of  chemically  pure  ether,  by  frequently 
pouring  from  test-tube  to  test-tube.  To  the  ether  extract 
are  added  15  drops  of  a  1  per  cent,  solution  of  benzidin 
powder  in  95  per  cent,  alcohol  (or  in  strong  glacial  acetic 
acid).  The  mixture  is  again  poured  from  one  test-tube  to 
another  several  times.  From  15  to  25  drops  of  active 
hydrogen  peroxide  are  finally  added  (commercial  peroxide 
of  3  per  cent,  strength  is  satisfactory). 

If  blood  is  present  in  the  gastric  extracts  a  prompt  color 
change  takes  place  in  the  fluid.  This  color  change  varies 
from  a  lively  emerald  green  to  a  greenish-blue  or  an  indigo. 
If  no  blood  is  present,  then  the  color  change  does  not  com- 
monly appear.  We  find  it  of  value  to  allow  the  tubes  to 
stand  1  minute  after  the  addition  of  the  peroxide  solution. 
If  no  greenish  or  bluish  color  has  developed,  it  is  safe 
to  say  that  any  blood  which  may  be  present  has  little  clinical 
significance. 

Instances  of  Altered  or  "Occult"  Blood  in  Retention  Con- 
tents.—Oi  the  483  cases  in  which  12-hour  retention  was 
proven,  the  clinical  test  for  altered  blood  was  positive  in 
82  per  cent.  Of  this  number,  as  is  noted  above,  lactic  acid 
was  present  in  66.8  per  cent. 

MICROSCOPIC  EXAMINATION  OF  RETENTION  CONTENTS 

This  should  never  be  neglected.  Apart  from  the  evi- 
dence of  stagnation,  in  the  large  majority  of  instances  of 


EXAMINATION    OF   GASTRO-INTESTINAL   FUNCTION     207 

moderately  advanced,  or  extensive  gastric  carcinoma,  even 
if  no  abdominal  tumor  can  be  palpated  externally,  one  is 
able  to  discover  a  rather  characteristic  picture  upon 
microscopic  examination  of  stained  smears  with  high-power 
amplification.  To  the  expert,  examination  of  unstained 
smears  is  usually  sufficient  to  return  a  diagnosis  as  to  the 
type  of  retention  contents.  However,  the  examination 
should  always  be  made  with  high  power.  Even  those  most 
experienced  in  the  microscopic  examination  of  gastric  ex- 
tracts cannot  determine  accurately  the  bacterial  flora 
present  using  the  4-mm.  or  lower  power  objectives. 

Method. — Various  methods  of  staining  are  in  clinical  use. 
Not  infrequently  the  desired  information  may  be  obtained 
by  the  so-called  3-drop  method.  This  is  performed  by  plac- 
ing upon  a  clean  glass  slide  3  small  drops  of  unfiltered 
retention  contents.  These  drops  are  placed  in  a  row  about 
^  of  an  inch  apart.  The  first  one  is  simply  covered  with 
a  clean  cover  slip ;  to  the  second  is  added  a  drop  of  Lugol's 
solution  and  then  a  cover  slip;  to  the  third  is  added  a  small 
drop  of  osmic  acid  and  a  cover  slip.  The  unstained  speci- 
men permits  of  search  for  motile  and  non-motile  organisms; 
the  second  drop,  on  account  of  the  iodine  stain,  permits  of 
examination  for  starch  and  vegetable  food  rests,  yeasts, 
leptothrix  and  the  like;  while  the  third  drop  allows  the 
recognition  of  fat  or  some  of  its  products.  If  the  cover  slips 
are  placed  firmly  upon  the  drops,  one  can,  with  the 
addition  of  a  small  amount  of  immersion  oil  to  each  cover 
slip,  quite  satisfactorily  examine  with  the  high  power. 

This  is  a  rough,  clinical  method,  and  is  of  limited  use  in 
an  investigation  of  gastric  contents  from  which  information 
is  desired  regarding  definite  flora,  food  digestion  and  the 
like. 

For  purposes  of  studying,  and  convenience  in  examining, 
a  large  number  of  specimens  in  a  short  time,  we  devised  the 
following  method.  We  have  found  it  quite  dependable  and 
simple  in  its  application. 


208  CANCER  OF  THE  STOMACH 

Colored  Agar  Method  for  Staining  Gastric  Extracts. — 

Agar  Solutions. — Two  per  cent,  agar  solution  is  made  by 
boiling  up  an  appropriate  quantity  of  best  grade  strip  agar 
in  distilled  water.  The  solution  is  filtered  several  times 
while  very  hot  through  double,  hydrochloric-acid-washed 
filter  paper.  On  cooling  it  solidifies  as  a  firm  jelly.  It 
should  be  fractionally  sterihzed  and  refiltered  on  3  con- 
secutive days. 

For  purposes  of  convenience,  5  cc.  of  the  molten  agar  are 
poured  into  each  of  numerous  sterile  test-tubes.  The 
tubes  are  plugged  with  sterile  cotton  and  set  aside  at  room 
temperature.     The  agar  jellies  and  may  be  used  as  desired. 

Stains. — Thus  far  we  have  used  coloring  agents  in  combi- 
nation with  agar  solutions  for  two  purposes:  (1)  for  the 
differentiation  of  bacteria,  blood-cells,  epithelial  elements, 
tissue-bits  and  the  like,  we  have  found  most  satisfactory 
Unna's  polychrome  methylene  blue;  (2)  for  the  differentia- 
tion of  starch  residues,  vegetable  fibers,  moulds,  etc.,  we 
have  employed  freshly  prepared  LugoFs  mixture. 

Procedure. — For  each  specimen  of  gastric  extract  or  feces 
emulsion,  we  make  t?wo  agar-coloring  matter  combinations 
as  follows:  the  2  per  cent,  agar  jelly  is  liquefied  by  heating 
over  a  Bunsen  flame,  or  in  a  water-bath.  Two  cubic  centi- 
meters of  the  solution  are  poured  into  each  of  two  small  test- 
tubes  (those  measuring  10  cm.  X  15  mm.  answer  very  well). 
Into  each  of  the  tubes  are  then  poured  15  drops  of  filtered 
staining  agent.  For  staining  bacteria  and  the  like  we  have 
found  that  Unna's  mixture  gives  good  results,  while  Lugol's 
solution  colors  starch  elements  better  than  simple  iodin. 
The  added  stains  are  intimately  mixed  with  the  agar  and 
the  tubes  promptly  placed  in  a  beaker  containing  boiling 
water.     The  agar  is  thus  kept  as  a  solution. 

Very  thin  smears  of  the  gastric  extracts  or  feces  emulsions 


EXAMINATION    OF   GASTRO-INTESTINAL   FUNCTION     209 

are  made  on  cover  slips.  It  is  desirable  to  avoid  getting 
gross  particles  of  food  in  the  smears.  The  smears  may  be 
dried  in  air  or  by  rapidly  passing  through  a  gas  flame. 

Onto  the  smear  to  be  examined  for  microorganisms  and 
allied  elements,  by  means  of  a  pipette  with  a  1  mm. 
bore,  is  placed  1  drop  of  the  agar-methylene-blue  mixture. 
The  cover  slip  is  promptly  inverted  on  a  clean  glass  slide. 
The  agar-stain  mixture  rapidly  spreads  to  the  edges  of 
the  cover  slip.  As  it  cools  the  agar  solidifies  while  the 
stain  mixed  with  it  permeates  the  smear.  Similarly,  to 
the  smear  to  be  examined  for  starch  remnants  and  the 
like,  is  added  1  drop  of  the  agar-Lugol's  mixture.  The 
cover  sHp  is  mounted  at  once  on  the  same  slide  as  the 
first  preparation.  About  1  minute  suffices  for  firmly 
mounting  and  staining  ordinary  material.  In  a  series, 
the  first  preparations  are  ready  for  examination  by  the 
time  the  last  are  made. 

Examination. — The  preparations  are  best  examined  by 
such  fight  as  comes  from  a  Nernst,  Schwann  or  tungsten 
lamp.  If  electricity  is  not  available,  a  Welsbach  mantle 
light  suffices.  'V^Tien  the  specimens  are  properly  focused, 
using  an  oil-immersion  objective,  it  will  be  seen  that 
bacteria  are  stained  blue  or  deep  purple;  blood  cells  and 
nuclei  are  differentiated  by  pale  pink  and  blue,  as  are  also 
epithefial  elements;  tissue  bits,  if  small,  may  show  atypical, 
mitotic  cells;  muscle  fibers  are  pink  to  red,  with  deeper 
striation;  mucus  is  in  bluish  strips  or  whorls.  Unless  the 
preparation  is  over-stained,  vegetable  fibers,  leptothrix, 
moulds,  etc.,  are  but  lightly  colored.  In  the  smear  pre- 
pared with  agar-Lugol's  mixture,  vegetable  fibers,  lepto- 
thrix, moulds,  and  starch  remnants  are  appropriately  dif- 
ferentiated. The  latter  may  be  amethyst-blue,  with 
deeper   staining   centers    or    laminae,    reddish-pink    with 

14 


210  CANCER   OF   THE    STOMACH 

mahogany-colored  centers  or  faint  pink  or  colorless.  Bud- 
ding yeasts,  moulds,  and  occasionally  bacteria  take  a 
brownish-blue  tinge.  Vegetable  cells  stand  out  promi- 
nently as  blue  to  brown  reticula.  Large  masses  of 
amorphous  material  stain  variously,  but  are  readily  dis- 
tinguished from  microorganisms. 

Uncolored  Preparations. — The  agar  without  coloring 
agents  added  may  be  advantageously  used  for  mounting 
smears.  In  fresh  preparations,  when  the  smears  are  not 
dried,  motile  organisms  (bacteria,  protozoa)  may  be  ob- 
served for  a  long  time.  This  is  facilitated  when  the  speci- 
men is  diluted  with  three  volumes  of  warm  normal  saline 
solution  before  the  smears  are  made. 

Advantages  of  the  Method. — A  routine,  differential  report 
on  two  dozen  smears,  from  half  as  many  specimens  of  gastric 
extracts  or  feces,  may  be  made  in  about  30  minutes.  The 
specimens  are  simultaneously  mounted  and  stained.  The 
solidification  of  the  agar  gives  so  firm  a  mount  that  the 
specimens  may  be  examined  with  high  or  low  power,  with 
the  stage  of  the  microscope  at  any  angle.  The  mounting 
is  suflficiently  permanent  to  allow  future  study  (we  have 
preparations  showing  good  fields  after  10  weeks),  drawings, 
photomicrographs  or  demonstration.  Comparison  of  the 
smears  on  the  same  slide,  but  differently  stained,  results  in 
many  interesting  and  instructive  observations.  There 
would  seem  to  be  advantages  in  using  the  method  for  the 
observation  of  motile  bacteria,  protozoa,  or  cells  with 
ameboid  activity,  when  uncolored  agar  solutions  are 
used. 

Significance  of  Microscopic  Examination. — ^In  malignant 
retention  contents,  food  in  the  various  stages  of  digestion 
can  usually  be  recognized. 

Food. — Unless   food   retention   has   been   demonstrated 


EXAMINATION    OF    GASTEO-INTESTINAL    FUNCTION      211 

macroscopically,  the  finding  of  food  bits  microscopically 
only  has,  in  our  experience,  practically  no  diagnostic  value. 

Bacteria  in  Malignant  Retention  Contents. — The  investi- 
gation has  occupied  laborator}^  workers  for  many  years.  It 
was  early  shown  by  Oppler  working  in  Boas'  Clinic  that 
malignant  retention  extracts  contained  a  large  number  of 
long,  non-motile  rods.  This  observer  also  noted  that 
such  organisms  were  of  comparatively  rare  occurrence  in 
gastric  contents,  either  of  the  retention  or  non-retention 
tj^e,  in  diseases  other  than  carcinoma  of  the  stomach. 
Later  investigations  upon  the  properties  of  these  so-called 
''rather  long  bacilli"  were  carried  on  by  Kauffmann. 
This  observer  proved  that  the  bacteria  described  by 
Oppler  and  Boas  were  acid  fast,  fermented  sugar,  and 
were  probabh'  an  altered  form  of  Bacillus  acidi  ladici. 

We  have  made  observations  upon  221  consecutive  in- 
stances of  gastric  cancer  for  the  presence  of  bacteria  of 
this  type.  We  were  early  impressed  by  the  fact  that 
the  bacillus  described  by  Oppler-Boas,  Kauffmann  and 
others  appeared  to  be  not  a  distinct  tj-pe,  but  rather 
partook  of  the  nature  of  a  group  of  bacteria  having  similar 
morphological  and  cultural  characteristics. 

In  addition  to  the  microscopic  examination  of  stained 
and  unstained,  wet  and  dry  smears  of  gastric  contents 
containing  this  organism,  we  undertook  to  attempt  culture 
of  the  germ  by  perhaps  a  new  method.  A  full  report  of  the 
work  is  not  yet  available.  Let  it  suffice  to  say  that  the 
information  of  the  greatest  worth  which  we  are  able  to 
derive  from  our  studies  was  derived  from  bacilli  from 
mahgnant  gastric  contents  grown  in  two  types  of  media, 
namely:  (a)  a  medium  made  from  extracting  fresh,  sterile 
mahgnant  tissue  that  had  been  ground  up  in  a  sterile 
meat  grinder  with  a  normal  salt  solution,  and  (h)  a  similar 


212 


CANCER    OF    THE    STOMACH 


medium  made  from  beef  extract.     We  are  prepared  to 
ofifer  the  following  morphological  observations. 

Characteristics  of  Bacilli  of  the  Oppler-Boas  Group.— 
The  bacilh  vary  in  length  from  15  to  60  microns.     The 


Fig.  50. — Typical     long     bacilli — Oppler-Boas.     Photomicrogram. 

(Author.) 


YiQ,  51. — Bent  and   club-shaped  forms   of   Oppler-Boas  bacilli.     Photo- 
microgram.— (Auth6r.) 

short  forms  are  straight,  slightly  curved,  wavy  or  occasion- 
ally comma  shaped.  As  the  forms  grow  larger,  they  rarely 
remain  straight,  but  may  be  bent  or  wavy  with  a  tend- 


EXAMINATION    OF    GASTEO-INTESTINAL    FUNCTION      213 

ency  to  curl  up  like  a  J  or  ''shinny "-stick  at  the  end.  In 
old  retention  contents  the  bacilli  may  assume  U-shape, 
half  circle  forms,  or  may  even  have  ring-like  twists. 

It  is  uncommon  to  find  Oppler-Boas  bacilli  over  20  mi- 
crons long  that  are  absolutely  straight.  When  they  are 
above  this  size  the  wavy  or  bent  forms  become  numerous. 
In  addition  to  being  bent  or  wavy,  one  frequently  notes 
that  an  end  of  a  bacillus  is  clubbed  or  bent  at  an  oblique 
angle. 


Fig.  52. — Oppler-Boas  bacilli  showing  different  groupings  and  variation 
in  size  of  individual  bacilli.     Photomicrogram. — (Author.) 

Long  chains  of  organisms  of  this  group  are  uncommon; 
short  chains  often  occur.  The  individual  bacilli  making 
up  the  chains  vary  in  length,  but  resemble  each  other, 
structurally.  When  the  bacilli  grow  in  chains  they  are 
usually  blunt  ended,  but  on  account  of  the  curved  or 
wavy  outline  of  the  individual  bacillus  the  resultant  chain 
often  has  an  irregular  zig-zag  appearance.  In  old,  stagna- 
tion contents,  some  of  these  chains  form  loops,  nearly 
complete  ellipses  or  circles. 

Staining  Properties. — The  typical  bacilli  stain  uniformly 


214 


CANXER    OF    THE    STOMACH 


a  bluish-purple  with  Unna's  polychrome  methylene  blue. 
They  absorb  the  blue  about  as  deeply  as  do  yeast  cells. 
As  the  baciUi  grow  longer  or  form  chains,  they  stain  ir- 
regularly so  that  frequently  there  are  alternate  bands  of 
deep  and  Hght  color.  This  gives  the  organism  a  some- 
what beaded  appearance.  It  may  be  that  this  bizarre 
staining  appearance  is  due  to  the  fact  that  the  organism 


Fig.  53. — Oppler-Boas  bacilli.     Showing  half-circle,    "shinny  stick"   and 
ring  forms.     Photomicrogram  of  old  retention  contents. — (Author.) 

is  wa,vj  or  corkscrew-like.  If  this  be  so,  different  portions 
of  the  bacillus  come  into  focus  at  different  times.  Cer- 
tainly some  of  the  more  hghtly  stained  areas  appear  darker 
upon  focusing.  The  bacilU  take  the  iodine  stain  evenly, 
and  are  colored  a  hght  amber-yellow  by  Lugol's  solu- 
tion. This  perhaps  helps  to  differentiate  them  from 
leptothrix  forms  and  from  ordinary  lactic  acid  bacilli. 

Artificial   Culture. — Two   types   of  culture  media  were 
used:  (1)   ordinary  beef   bouillon,  and  (2)  bouillon  made 


EXAZMIXATIOX    OF    GASTEO-IXTESTIXAL    FrXCTIOX      215 

from  fresh  cancer  tissue.  The  tubes  were  inoculated 
from  a  cancerous  retention  contents.  Its  acidity  was: 
total,  15;  free  Hcl^  0. 

Moxroscopic  Examination. — After  24  hours  the  tubes 
containing  bacilli  in  the  cancer  extract  medium  were 
slightly    opalescent    and   had    a    fine,    granular,    compact 


Fig.  54. — ^losaic  of  yeast  cells  from  case  of  benign  retention.     Photomicro- 

gram. — (Author.) 

precipitate  on  the  bottom.  The  cultures  had  a  slightly 
3^east-hke  odor.  Cultures  made  in  the  heef  houillan 
medium  were  densely  opaque,  and  had  a  heavy,  fiocculent 
precipitate  with  faint  yeast}^  odor. 

Microscopic  Examination. — Smears  made  from  the  can- 
cer extract  houillon  exhibited  an  occasional  yeast  cell  and 
from  3  to  6  bacilli  of  the  Oppler-Boas  type  to  a  field.  The 
bacilli  were  single  or  arranged  in  short  chains  in  from 
2  to  -4  organisms.     They  were  fairly  even  in  length,  the 


216  CANCER  OF  THE  STOMACH 

average  being  about  20  microns.  Thej^  stained  deeply 
and  homogeneously  with  Unna's  polychrome  methylene 
blue.  Some  had  rather  club-shaped  ends;  those  of  others 
were  slightly  angulated.  The  ends  were  bluntly  rounded. 
The  individual  bacilU  joined  each  other  in  the  chains  at  a 
broad  oblique  angle.  In  this  medium  were  also  seen 
numerous  slender  somewhat  lance-shaped  bacilH,  arranged 
singly.  They  were  occasionally  curved  at  the  middle, 
like  a  wide  open  U.     Thej^  stained  rather  faintly.     With 


Fig.  55. — Yeast   colony  from  case  of  beniiin  gaitric   retention.      Photo- 
microgram. — (Author,  j 

Lugol's  mixture,  organisms  of  the  Oppler-Boas  tA'pe  were 
colored  Hght  amber-yellow,  as  were  also  the  lance-shaped 
bacilh  above  described.  Occasionally  one  could  see  forms 
of  the  lance-shaped  baciUi  arranged  singly  and  staining 
deeply.  The  average  length  of  the  small  variety  of  these 
was  three-fourths  that  of  the  diameter  of  a  red  blood 
cell.  The  large  forms  were  twice  as  long  as  the  diameter 
of  a  red  blood  cell. 

Cultures  in  Beef  Bouillon. — ^The  growth  was  very  abun- 
dant.    Great  numbers   of  Oppler-Boas  bacilli  were  seen. 


EXAMIXATIOX    OF    GASTEO-IXTESTIXAL    FrXCTIOX      217 

They  varied  \'ery  much  in  size  ranging  in  length  from  half 
the  diameter  of  a  red  blood  cell  to  3  times  that  diameter. 
They  stained  deeply.  Their  ends  were  bluntly  rounded. 
The  organisms  were  straight  or  somewhat  bent  in  the 
middle  or  toward  one  end.     Without  regard  to  individual 


Fig.  56. — Old    benign    gastric  retention.     Yeasts  and  bacillus    butyricus. 
Phot  omicrogram . — (Author . ) 

size  they  were  arranged  in  short  chains  or  pairs.  TThen 
forming  chains  they  rarely  fitted  squarely  end  to  end, 
but  usually  at  an  angle.  Sometimes  the  bacilli  were 
joined  at  different  or  opposite  angles  so  that  h-regular 
chains  were  formed.  Occasionally,,  the  angles  were  similar 
in  dhection.     In  this  event  curved  chains  resulted.     ]\Iany 


218 


CANCER   OF   THE    STOMACH 


long  leptothrix  chains  were  seen.  These  were  much 
branched,  bent,  twisted  and  in  irregular  tangles.  They 
stained  more  lighth'  than  did  the  Oppler-Boas  bacilli. 
The  individual  segments  of  these  chains  were  usually  nar- 
rower and  longer,  rarely  being  less  than  30  microns.     They 


Fig. 


57. — Yeasts  and  sarcmae  in  case  of  benign  retention. 
gram. — (Author.) 


Photomicro- 


took  the  stain  not  so  evenly  as  did  the  Oppler-Boas  type 
of  organism,  and  their  ends  were  rather  acutely  pointed  or 
curved.  Stained  with  LugoFs  mixture,  the  Oppler-Boas 
baciUi  in  this  medium  were  faintly  amber.  Leptothrix 
were  more  deeply  colored. 

After  48    hours,  macroscopicalh^    the    culture    on    the 


EXAMIXATIOX    OF    GASTRO-IXTESTIXAL    FUXCTIOX      219 

cancer  medium  was  so  heavy  as  to  render  the  bouillon 
completely  opaque.  There  was  a  heavy,  coarse,  flocculent 
precipitate.  On  the  surface  of  the  medium  was  a  thin, 
grayish- white,  superficial  pelHcle.  The  culture  had  a 
musty  odor.     Microscopic  examination  of  stained  smears 


Fig.  oS, — C'ppler-Buus  Ixjcilli  imm  artificial  uuiture  cancer  extract 
bouillon)  showing  variations  in  size,,  and  different  groupings.  Photomi- 
crogram. — (Author.; 

showed  an  enormous  number  of  short,  thick  bacilli  in 
small  groups  and  clumps.  Their  average  length  was 
4  to  6  microns.  They  stained  rather  irregularly,  some 
having  beaded  or  club-shaped  ends.  They  seemed  dif- 
ferent from  another  organism  present,  a  bacillus  staining 
regularly  and  6  to   12  microns  long.     These  occurred  in 


220  CANCER  OF  THE  STOMACH 

short  chains  or  singly.  These  forms  were  distinctly 
club  shaped,  the  clubbed  portion  staining  rather  hghtly 
(vacuole?).  When  club  shaped,  these  bacilli  were  always 
single.  The  smear  showed  also  many  round  or  oval 
sHght  vacuolated  cocci  about  2  microns  in  diameter.  These 
resembled  very  much  the  clubbed  ends  of  the  bacilli 
above  described.  Occasionally,  one  could  see  a  bacillus 
longer  than  12  microns,  in  which  the  vacuolated  clubbing 
appeared  at  each  end.  There  were  a  few  bacilli  in  which 
this  vacuolation  and  clubbing  occurred  in  the  middle. 
The  non-clubbed  forms  were  straight  or  sUghtly  bent  rods 
with  an  average  length  of  8  microns.  They  were  frequently 
in  short  chains,  arranged  at  angles  to  each  other,  or  form- 
ing small  loops  like  a  twisted  whip-lash.  Sometimes  the 
long,  straight  variety  was  rather  obUquely  angulated  at 
one  end.  Occasionally,  what  appeared  to  be  separated 
clubbed  ends  of  bacilli  formed  large  colonies  of  coccus- 
hke  organisms.  In  these  the  transition  from  the  clubbed 
end  to  the  coccus  form  could  be  seen  in  all  stages.  Also 
it  would  seem  that  long,  straight  baciUi  were  gradually 
changed  into  the  variety  with  clubbed  ends.  No  yeasts  or 
leptothrix  were  seen. 

Cultures  in  Beef  Bouillon  after  48  Hours. — These  cultures 
were  sUghtly  cloudy.  There  was  a  coarse,  flocculent  pre- 
cipitate.    They  had  a  sHghtly  musty  odor. 

Microscopic  examination  of  stained  smears  showed 
enormous  numbers  of  leptothrix  in  the  form  of  large, 
single,  wa^-y  segments,  varying  in  length  from  6  to  100, 
plus,  microns.  Occasionally  there  was  branching,  but 
usually  end-to-end  union  occurred.  The  segments  joined 
each  other  at  angles.  Sometimes  the  leptothrix  were 
arranged  in  coarse  networks,  loosely  wound  skeins,  spirals 
or  whorls.     They  stained  very  irregularly  with  resultant 


EXAJVIIXATIOX    OF    GASTRO-INTESTINAL   FUNCTION      221 

light  and  dark  areas  alternating.  Occasionally,  they  pre- 
sented a  coarsely  beaded  appearance.  Comparatively  few 
long  bacilli  of  the  Oppler-Boas  type  were  seen.  These 
were  usually  arranged  in  small  groups  or  occurred  singly. 
They  varied  in  length  from  6  to  20  microns.  They  were 
usually  straight  or  slightly  curved.  Their  ends  were 
rather  blunt  or  angulated.  Xo  clubbed-  or  bulbed-shaped 
ends  were  seen.  Xo  vacuolated  forms  were  noted.  They 
stained  rather  ii^regularly.  Short  chains  occasionally  oc- 
curred. These  were  made  up  of  2  to  4  organisms  often 
arranged  at  sharp  angles  with  each  other.  Stained  with 
Lugol's  solution,  leptothrix  were  colored  amber-yellow 
with  no  shade  of  blue,  and  took  a  color  somewhat  darker 
than  do  Oppler-Boas  bacilli. 

Cultures  after  72  Hours. — The  growths  on  cancer 
extract  medium  were  densely  opaque  and  had  a  faint 
musty  odor.  Stained  specimens  showed  an  abundant 
growth  of  rods  which  varied  in  length  from  4  to  18  microns. 
They  were  arranged  singly,  in  pairs  and  in  angulated 
chains,  of  from  2  to  5  organisms,  or  in  compact  masses. 
The  larger  rods  were  often  shghtly  curved  or  bent  at  the 
middle  or  toward  one  end.  They  stained  deeph'  and 
usually  homogeneously.  Their  ends  were  commonly 
bluntly  rounded,  but  some  were  almost  square.  The 
medium-size  or  the  small  rods  were  most  often  club 
shaped  or  bulbed  at  one  end.  In  this  bulbed  end  was  a 
spore-like  body  which  did  not  stain  so  densely  as  does  the 
shaft  of  the  rod.  These  forms  were  thicker  and  usually 
single  or  closely  arranged  in  clumps.  A  number  of  round 
or  ovoid  spore-like  bodies  appeared  irregularly.  A  few 
curved  chains  or  loop-like  strings  were  seen.  These  were 
made  up  of  curved  or  bent  bacilH.  Xo  leptothrix  or 
veasts  were  seen. 


222  CANCER  OF  THE  STOMACH 

Seventy-two-hour  Growth  in  Beef  Bouillon. — The  medium 
was  rather  heavily  clouded.  There  was  a  coarse,  granular 
precipitate.  Microscopic  examination  revealed  leptothrix 
in  dense  networks,  skeins,  whorls  and  bands.  These  chains 
were  made  up  of  irregularly  branching  strands  or  long 
organisms  crossing  each  other  in  every  direction.  Occa- 
sionally a  bacillus  resembling  the  Oppler-Boas  type  was 
seen,  but  no  spore-Hke  forms  or  bacilli  with  clubbed  ends 
were  found.     No  yeasts  were  present. 

Macroscopic  Examination  of  Oppler-Boas  Cultures  after 
96  Hours. — The  cancer  extract  medium  was  somewhat 
opalescent.  There  was  a  coarse,  heavy,  granular  sticky 
precipitate. 

Beef  bouillon  cultures  were  cloudy.  There  was  a  thick, 
stringy,  gelatinous  sediment. 

Microscopic  Examination. — Stained  smears  from  the 
cancer  medium  cultm'es  revealed  very  few  long  rods. 
Those  that  were  present  were  shghtly  bent  or  curved  in  the 
middle  and  were  usually  single.  Some  of  the  long  rods 
were  slightly  club  shaped  at  one  end.  They  stained 
deeply  and  had  blunt  ends.  There  were  manj^  spore-Hke 
bodies  that  appeared  larger  than  in  the  72-hour  culture. 
Many  of  them  were  elongated  and  a  few  were  dumb-bell 
shaped.  Sometimes  these  spore-like  bodies  were  joined 
end^to  end  and  formed  short  chains  of  from  2  to  3  pairs  of 
spores.  An  occasional  leptothrix  was  seen.  It  usually 
formed  a  thin  strand. 

Cultures  in  the  beef  bouillon  medium  showed  enormous 
numbers  of  leptothrix.  These  were  single  or  grouped  in 
skeins,  whorls,  or  dense  masses.  They  usually  stained 
diffusely.  There  were  no  clubbed  or  dumb-bell  shaped 
bodies  nor  any  spore-like  structures.  With  Lugol's  solution 
they  stained  light  amber. 


EXAMINATION    OF   GASTRO-INTESTINAL   FUNCTION     223 

Macroscopic  Examination  of  Oppler-Boas  Cultures  after  120 
Hours. — Growths  in  the  cancer  medium  were  cloudy  with 
abundant  coarse,  granular  sediment  and  a  rather  yeast- 
like odor. 

Cultures  in  the  beef  bouillon  were  very  cloudy.  On  their 
surface  was  a  slimy  pellicle.  There  was  a  thick,  flocculent 
sediment  and  a  strong,  rather  acid  odor. 

Microscopic  Examination  of  Cultures. — Smears  from  the 
cancer  medium  revealed  an  abundant  growth  of  organ- 
isms from  6  to  20  microns  long.  They  were  arranged  in 
long  chains,  loose  groups  or  parallel  bands.  These  organ- 
isms were  bacilli,  and  while  the  majority  of  them  were 
straight,  the  small  ones  were  slightly  curved.  There  were 
also  long  bacilli  which  were  curved  at  the  middle  and 
occasionally  wavy.  When  they  formed  chains,  the  bacilli 
joined  end  to  end  at  an  angle.  In  the  very  large  bacilli 
there  were  many  with  club-like  endings.  Short  chains 
were  occasionally  seen.  These  had  a  zig-zag  appearance  or 
formed  curves  or  loops.  The  smaller  bacilli  sometimes 
showed  bipolar  staining  but  as  a  rule  they  stained  fairly 
deeply  and  uniformly.  The  longer  bacilli  rarely  showed 
irregular  staining.     No  spore-like  bodies  were  seen. 

Cultures  in  beef  bouillon  showed  enormous  growth  of 
leptothrix  arranged  in  chains,  loops,  skeins,  twists,  circles 
or  long,  single  strands.  There  were  many  long,  slender 
individual  segments.  These  individual  organisms  appeared 
about  half  the  width  of  the  Oppler-Boas  bacilli  and  varied 
greatly  in  length,  so  that  without  segmentation  one  might 
stretch  across  several  microscopic  fields  (high  power). 
Where  segmentation  occurred,  the  new  segment  fre- 
quently grew  from  the  main  one  at  a  very  sharp  angle. 
These  organisms  stained  uniformly.  There  were  no  bi- 
polar bodies. 


224 


CANCER   OF   THE    STOMACH 


Small  individual  bacilli  were  also  seen.  They  were  from 
1  to  3  microns  in  length.  Their  ends  were  lance  shaped. 
Thej^  were  arranged  in  short  chains.  They  never  formed 
whorls  or  compact  masses.  There  were  no  spore-hke 
bodies  or  any  organisms  that  showed  bipolar  staining. 
No  yeasts  were  seen. 

Table  17 


Total 

Sarcinse 

Yeasts 

O.B. 

Lactic 

Abs. 
Hcl 

Food 
rem- 
nants 

Tumor 

Occult 
blood 

Sarcinae 

71 

0 

36 

65 

20 

31 

42 

56 

48 

Yeasts 

150 
221 

36 
65 

0 
116 

116 
0 

38 
50 

76 
132 

116 

178 

117 
186 

104 

Oppler-Boas. . . . 

172 

Lactic  acid 

85 

20 

38 

50 

0 

44 

57 

64 

76 

Ab.  free  HCl. . . 

180 

31 

76 

132 

44 

0 

130 

128 

120 

Remnants 

194 

42 

116 

178 

57 

130 

0 

146 

142 

Tumor 

208 
202 

46 
48 

117 
104 

186 
172 

64 
76 

128 
120 

146 
142 

0 
147 

147 

Occult  blood . . . 

0 

Showing  the  Clinical  Interrelationship  Existing  between  Important  Test- 
meal  Findings  and  the  Presence  of  Abdominal  Tumor. — (Author.) 

Frequency  of  Occurrence  of  Oppler-Boas  Bacilli  in  Gastric 
Cancer. — In  221  consecutive  cases  of  the  disease,  in  our 
series,  organisms  of  the  Oppler-Boas  type  were  noted  in 
93.6  per  cent.  Yeasts  were  associated  in  52  per  cent,  and 
sarcinse  in  29  per  cent. 

Table  17  has  been  constructed  to  summarize  the  relation- 
ship between  the  presence  of  Oppler-Boas  bacilli,  abdominal 
tumor  and  main  test-meal  data. 


EXAMINATION  OF    SECRETORY  FUNCTION    OF  THE    STOMACH 
IN  GASTRIC  CANCER 

A  test-meal  is  employed.  It  should  be  easily  prepared, 
palatable  and  contain  essential  food  elements.  We  have 
found  useful  a  meal  consisting  of 

1.  Sixty  grams  of  second-day  wheat  flour  bread  and 
500  cc.  of  luke  warm  water,  or, 


EXAMINATION    OF    GASTEO-INTESTINAL    FUNCTION      225 

2.  Two  shredded  wheat  biscuits  and  500  cc.  of  luke  warm 
water  or  weak  tea  (Dock),  or, 

3.  Sixty  grams  of  zweiback  and  500  cc.  of  luke  warm 
water  or  weak  tea. 

Generally,  the  meal  is  removed  by  means  of  a  stomach 
tube  at  the  end  of  50  minutes.  In  instances  where  the 
stomach's  emptying  rate  is  rapid,  the  test-meal  should  be 
removed  from  20  to  40  minutes  after  it  has  been  eaten. 

Macroscopic  Study  of  Removed  Contents. — In  retention 
cases,  unless  the  stomach  has  been  thoroughly  lavaged 
before  the  administration  of  the  secretory  meal,  the  test 
food  may  not  be  recognizable,  on  account  of  its  admixture 
with  stagnant  gastric  residue.  In  non-retention  cases, 
the  test-food  appears  poorl}'  chymified,  mixed  with  mucus 
and  is  often  tinged  with  blood  or  bile. 

The  amount  varies.  Of  course,  if  gastric  retention  exists, 
the  quantity  removed  ma}'  be  even  greater  than  that  of 
the  test-meal  given.  In  non-retention  cases,  from  50  cc. 
to  150  cc.  are  usually  recovered.  If  a  gristle-like  cancer 
holds  open  a  pylorus,  the  amount  regained  may  be  but  a 
few  cubic  centimeters. 

The  odor  is  characteristic  only  where  retention,  hemor- 
rhage or  sloughing  exists.  The  gastric  extracts  may 
then  have  rancid,  flesh}^,  or  putrid  odors.  In  non-reten- 
tion cases,  the  odor  is  not  uncommonly  of  a  peculiar,  nau- 
seating sweetness. 

Acidity. — In  retention  cases,  the  average  total  acidity  of 
the  secretory  meal  was  32.  The  minimum  was  2.  The 
maximum  was  67.  In  non-retention  cases,  the  average 
totalacidity  was  15.  The  minimum  was  2.  The  maximum 
was  44. 

Free  hydrochloric  acid  averaged  9.2  in  those  cases  where 
retention  had  been  proved.     The  minimum  was  0  and  the 

15 


226  CANCER  OF  THE  STOMACH 

maximum  29.  TSTiere  retention  did  not  exist,  the  average 
free  hydrochloric  acid  was  17.4.  The  minimum  was  0 
and  the  maximum  73. 

''Combined"  acidity  averaged  13.2.  The  minimum  was 
0  and  the  maximum  was  104.  In  the  non-retention 
group,  the  average  combined  acidity  was  7.1.  The 
minimum  was  0  and  the  maximum  27. 

Lactic  acid  was  present  in  the  secretory  meal  of  34.3 
per  cent,  of  the  retention  cases  and  16  per  cent,  of  the 
non-retention  cases. 

Altered  (''occult")  blood  was  demonstrated  by  the 
benzidin  or  guaiac  tests  in  68  per  cent,  of  the  retention 
cases  and  in  56.6  per  cent,  of  cases  of  the  non-retention 
group. 

Microscopic  examination  of  the  secretory  meal  revealed 
bacilli  of  the  Oppler-Boas  tj^pe  in  87.2  per  cent,  of  the 
retention  group  and  in  36  per  cent,  of  the  non-retention 
class. 

Gluzinski's  Method  of  Determining  Acidity. — In  gastric 
cancer  or  in  cases  where  a  peptic  ulcer  is  suspected  of  being 
carcinomatous,  Gluzinski  claims  that  the  relative  increase 
in  acidity  after  different  test-meals  aids  in  the  segrega- 
tion of  the  two  conditions.  The  method  is  particularly  in- 
structive in  the  cases  in  which  an  ulcer  is  beginning  to 
develop  cancerous  degeneration.  The  contents  of  the  fast- 
ing stomach  are  siphoned  out  in  the  morning  and  the 
findings  recorded  as  to  amount,  color,  odor,  relics  of  food, 
blood,  etc.,  litmus  reaction,  free  acid  with  Congo  paper 
and  free  acid  with  phloroglucin-vanillin ;  lactic  acid  with 
Strauss  or  Uffelmann  tests,  and  occult  blood  with  the 
guaiac-turpentine  test.  The  amount  of  free  acid  and 
total  acid  is  determined  by  titration.  The  microscopic 
findings  are  also  recorded.      Then  the  stomach  is  washed 


EXAMINATION    OF   GASTEO-INTESTINAL   FUNCTION     227 

out  clean  with  tepid  water  and  an  Ewald-Boas  test  break- 
fast is  given.  Forty-five  minutes  later  the  stomach  con- 
tents are  siphoned  out  again  and  the  stomach  thoroughly- 
rinsed  out  anew.  The  test-dinner  is  then  given:  about  100 
grams  of  chopped  roast  veal  or  boiled  beef;  150  grams 
potato  cooked  with  20  grams  fat  and  no  fluid.  The  stomach 
contents  are  siphoned  out  anew  after  2  hours.  All  this 
is  done  on  one  day.  The  finding  of  larger  amounts  of 
hydrochloric  acid  after  the  test-dinner  speaks  for  ulcer; 
smaller  proportions,  for  cancer.  The  insufiiciency  of  the 
stomach  mucosa  is  revealed  by  the  lack  of  acid  after  the 
test-dinner,  even  when  some  acid  was  found  after  the 
test-breakfast.  Fordo  regards  such  findings  as  absolutely 
conclusive  in  dubious  cases.  He  tabulates  the  findings 
in  26  ulcer  cases  and  comments  on  the  value  of  the  in- 
formation thus  derived.  In  4  other  cases  the  findings 
proved  dubious  and  the  course  of  the  cases  showed  that 
the  ulcer  at  the  time  must  have  been  just  starting  malignant 
degeneration.  This  procedure  is  one  of  much  promise, 
and  should  be  tried  in  doubtful  cases  as  a  matter  of  routine. 
Negative  information  should  never,  however,  postpone 
laparotomy  where  the  clinical  history  is  suggestive. 

Tests  for  Gastric  Ferments  in  Gastric  Cancer. — Rennin 
and  Pepsin. — It  would  appear  that  there  is  still  much 
uncertainty  as  to  the  inter-relationship  existing  between 
acidity  and  ferment  activity  in  gastric  ailments.  This  is 
particularly  the  case  in  gastric  cancer.  It  appears  that 
proteolysis  is  closely  associated  with  the  presence  of  free 
hydrochloric  acid,  so  long  as  the  acid  concentration  is 
below  0.4  per  cent.,  and  that  milk-curdling  ferment  follows 
similar  laws.  In  malignancy  peptolysis  appears  to  be  in- 
creased at  the  expense  of  proteolysis.  However,  Pelosi 
states  that  in  gastric   cancer  the  excess   of  milk-curdling 


228  CANCER  OP  THE  STOMACH 

ferment  and  of  -the  proteid  digesting  ferment  are  diag- 
nostic in  doubtful  cases,  where  Hcl  is  absent.  It  would 
seem  that  lactic  acid  bacilli  may  exist  in  these  cases  of 
achlorhydria  and  that  they  may  be  responsible  for  in- 
creased milk  curdling.  As  we  show  below  (vide  Glycyl- 
tryptophan  Test),  peptid-splitting,  enzyme-like  agents 
seem  to  be  present  in  more  than  40  per  cent,  of  cases  of 
cancer  of  the  stomach. 

Edestin  Test  ("Peptic  Index")  of  Fuld  and  Levison. — 
According  to  these  investigators  the  peptic  power  of 
gastric  juice  in  cancer  of  the  stomach  is  diminished.  Con- 
firmatory observations  have  been  made  by  Schryver  and 
Singer.  Edestin  is  very  difficult  to  obtain  pure,  com- 
mercially, but  may  be  made  in  a  well-equipped  laboratory. 
The  latter's  modification  of  the  original  test  is  as  follows: 

A  pure  preparation  of  edestin  may  be  obtained  in  the 
laboratory  by  recrystallization  from  warm  salt  solution. 
From  this  is  made  a  solution  of  0.1  per  cent,  of  edestin  in 
0.12  per  cent,  hydrochloric  acid  {i.e.,  30  cc.  normal  Hcl 
in  1  liter  distilled  water.  Such  a  solution  of  edestin  need 
not  be  made  freshly  for  each  observation,  but  that  if  used 
as  stock  it  must  be  stored  at  zero  temperature) .  Into  each 
of  10  small  test-tubes  2.5  cc.  of  this  solution  are  pipetted  and 
left  to  take  the  temperature  of  the  room  (10  to  20°  C). 
Into  each  test-tube  is  now  dropped  0.1,  0.2,  0.3,  0.4,  .  .  . 
to  1.0  cc.  (in  ascending  series)  of  the  gastric  juice  under 
investigation  previously  diluted  to  one-tenth  of  its  natural 
strength.  Each  test-tube  is  shaken  and  left  to  stand.  After 
30  minutes  have  elapsed  0.3  cc.  of  a  saturated  solution  of 
sodium  chlorid  is  added  to  each  tube.  If  digestion  has 
proceeded  to  a  certain  point,  the  solution  remains  clear, 
while  with  lower  degrees  of  digestion  a  white  cloudiness 
immediately  develops. 

The  peptic  iridex  in  any  case  is  designated  as  the  number 
of  tenths  of  a  cubic  centimeter  of  a  diluted  juice  added  to  the 
first  clear  test-tube  and  divided  into  100.  This  gives  as  a 
range  of  possible  readings  the  ten  numbers  100  (i.e.,  100/1), 


EXAMINATION   OF   GASTRO-INTESTINAL   FUNCTION      229 

50  (i.e.,  100/2),  33  {i.e.,  100/3),  25,  20,  17,  14,  12,  11  and 
10.  For  greater  accuracy  intermediate  amounts  of  diluted 
gastric  juice  may  be  added,  as  0.125,  0.150,  0.175  (between 
0.1  and  0.2),  etc.,  but  with  practice  it  becomes  possible  to 
read  such  intermediate  numbers  without  recourse  to  actual 
experiment.  The  average  of  healthy  cases  is  about  50. 
Cases  do  occasionally  present  themselves  with  an  index 
above  100  (i.e.,  in  which  even  the  test-tube  containing  only 
0.1  cc.  of  diluted  juice  remains  clear  on  the  addition  of  the 
salt  solution).  In  such  instances  recourse  must  be  had  to 
the  use  of  more  diluted  juice.  At  the  other  extreme,  how- 
ever, it  is  seldom  necessary  to  take  readings  below  an  index 
of  10  (i.e.,  in  which  even  the  test-tube  containing  1.0  cc. 
of  diluted  gastric  juice  develops  cloudiness  on  the  addition  of 
salt  solution),  for  in  such  cases  our  experience  seems  to  show 
that  digestive  power  is  probably  almost  absent. 

We  have  examined  108  cases  of  gastric  disease  by  the 
method  of  Fuld  and  Levison.  The  results  thus  far  ob- 
tained would  appear  to  indicate  that  early  and  advanced 
cases  of  carcinoma  where  free  hydrochloric  acid  is  low 
exhibit  high  peptolysis  and  low  proteolysis.  In  benign 
peptic  ulcers  both  peptolysis  and  proteolysis  are  low,  if 
acids  are  reduced. 

Formol  Index. — We  have  made  observations  upon  827 
instances  of  gastric  disease  for  the  detection  of  specific 
ereptases  in  stomach  juice.  We  have  used  the  modifi- 
cation of  the  formaldehyde  titration  method  of  Sorenson 
and  Schiff,  suggested  by  Schryver  and  Singer. 

Method. — 20  cc.  of  a  filtered  5  per  cent,  solution  of  Witte's 
peptone  are  mixed  with  1  cc.  of  the  filtered  juice  under 
examination.  Another  sample  of  a  similar  solution  is 
mixed  with  10  cc.  n/10  sodium  hydroxide  solution,  to 
which  is  also  added  1  cc.  of  the  gastric  juice.  Similar 
mixtures  without  addition  of  juice  are  kept  as  controls, 
and  all  the  4  samples  are  incubated  for  20  to  24  hours  at 
37°,  with  the  addition  of  1-2  cc.   of  toluene  to  prevent 


230  CANCER    OF   THE    STOMACH 

putrefaction.  After  removal  from  the  incubator,  each 
sample  was  treated  with  10  cc.  of  40  per  cent,  formalde- 
hyde solution  (commercial  formalin),  previously  neu- 
trahzed  to  phenolphthalein  by  sodium  hydroxid,  and  con- 
taining, therefore,  some  of  the  indicator  (about  }i  cc.  of 
0.5  per  cent,  solution  of  phenolphthalein  in  50  per  cent, 
alcohol  to  each  10  cc.  of  formahn).  The  formaldehyde- 
peptone  mixture  was  then  immediately  titrated. 

In  our  experience,  the  average  formol  titration  index  in 
87  instances  of  operatively  proved  gastric  cancer  was  22.3; 
the  average  index  in  22  cases  of  ulcus  carcinomatosum 
19.8;  the  average  index  in  99  cases  of  duodenal  ulcer,  12.4; 
of  57  cases  of  benign  gastric  ulcer  11.6;  of  32  cases  of 
benign  achylia  gastrica,  14.1;  of  16  instances  of  pernicious 
anemia,  14.5  and  5  cases  of  cancer  of  the  liver,  4.25.  It 
would  appear  that,  in  certain  cases,  the  estimation  of  the 
ereptic  power  of  gastric  juice  toward  peptone  solutions  is 
of  considerable  value  when  interpreted  in  the  light  of 
other  clinical  findings. 

Glycyltryptophan  Test. — Various  workers,  notably  Miil- 
ler,  Fischer,  and  Abderhalden  have  reported  that  malig- 
nant neoplasmata  contain  certain  peptidolytic  enzymes. 
This  discovery  appeared  to  have  clinical  value  when  Neu- 
bauer  and  Fischer  announced  that  simple  peptids,  par- 
ticularly the  dipeptid,  glycyltryptophan,  were  hydrolyzedby 
cancerous  ferments.  In  the  case  of  glycyltryptophan  the 
amino-acid  tryptophan,  which  is  liberated  by  this  cleav- 
age, can  be  recognized  readily  in  acid  solution  by  the 
rose-pink  color  occurring  on  the  addition  of  bromine.  This 
reaction  forms  the  basis  of  the  ^'glycyltryptophan  test" 
for  cancer  of  the  stomach,  advanced  by  Neubauer  and 
Fischer. 

Clinicians    generally    have    disagreed    widely    on    the 


EXAMINATION   OF   GASTRO-INTESTINAL   FUNCTION      231 

actual  value  of  the  test.  The  reaction's  sponsors,  together 
with  Lyle  and  Kober  and  Weinstein,  early  reported  en- 
thusiastically on  the  procedure.  Later  observers,  es- 
pecially Warfield,  Oppenheim,  Kohlenberger  and,  most 
recently,  Sanford  and  Rosenbloom,  declare  that  the  test 
is  of  dubious  value.  They  admit  that  while  certain  cases 
of  cancer  of  the  stomach  undoubtedly  give  the  reaction, 
many  non-malignant  gastric  disturbances  give  similar 
tests.  Factors  claimed  to  influence  the  reliability  of  the 
reaction  are  swallowed  saliva  and  bacteria,  bile  or  blood  in 
the  gastric  extracts,  low  or  absent  free  hydrochloric  acid 
and  regurgitated  duodenal  contents. 

In  October,  1911,  Weinstein  announced  that  he  had 
improved  on  the  Neubauer  and  Fischer  test.  He  stated 
that  in  extracts  from  cases  of  carcinoma  ventriculi  there 
exist  free  amino-acids,  notably  tryptophan,  and  that  the 
latter  can  be  tested  for  directly  with  bromine.  This  pro- 
cedure appeared  to  render  unnecessary  the  addition  of 
glycyltryptophan  to  such  gastric  contents,  with  search  for 
its  cleavage  products  subsequently.  This  so-called  'tryp- 
tophan test"  was  claimed  as  a  reaction  pathognomonic 
of  cancer  of  the  stomach.  Weinstein  did  not,  however,  go 
so  far  as  to  state  just  how  early  in  the  progress  of  the 
disease  this  test  could  be  regarded  as  pathognomonic. 
Certainly,  in  the  clinical  cases  which  he  briefly  quoted, 
when  the  tryptophan  test  was  positive,  other  evidences 
of  cancer  were  not  lacking.  Recently  Hall  and  William- 
son and  Sanford  and  Rosenbloom  have  recorded  ob- 
servations which  appear  to  indicate  that  Weinstein's 
test  has  even  less  value  than,  in  their  experience,  had  the 
glycyltryptophan  test. 

We  have  tested  more  than  1,400  gastric  extracts  for 
the  glycyltryptophan  and  the  tryptophan  reactions.     On 


232  CANCER  OF  THE  STOMACH 

1,175  different  individuals,  the  gastric  extracts  were  tested 
according  to  the  modification  of  the  glycyltryptophan 
and  the  tryptophan  tests  recently  suggested  by  me. 
This  modification  appears  to  have  the  advantages  of 
requiring  less  of  the  test  ingredients  than  the  Neubauer 
and  Fischer  method,  of  being  a  controlled  procedure, 
and  one  in  which  the  end-reaction  may  be  easily  deter- 
mined. It  is  our  purpose  at  this  place  to  include  our 
experience  with  the  cases  tested  by  this  uniform  method. 
The  test  is  set  up  as  follows: 

Test-tubes  of  10  cc.  capacity  are  employed.  These 
should  be  carefully  cleaned  with  boiling  water  and  dried 
inside.  They  are  numerically  marked  for  identification 
with  a  wax  pencil.  Into  each  test-tube  is  carefully  meas- 
ured, by  means  of  a  sterile  graduated  pipette,  0.5  cc.  of  the 
glycyltryptophan  solution.  Five  cc.  of  the  recently  se- 
cured filtered  gastric  extract  are  then  measured  by  a  clean, 
graduated  pipette  and  poured  into  the  correspondingly 
numbered  test-tubes  to  which  glycyltryptophan  solution 
has  already  been  added.  Two  control  tubes  are  used.  In 
one  is  placed  0.5  cc.  of  glycyltryptophan  solution  and  5  cc. 
of  normal  salt  solution,  and  into  the  other  is  placed  5  cc. 
of  normal  salt  solution,  without  adding  glycyltryptophan 
solution.  In  the  entire  series,  each  tube  next  receives  0.5 
cc.  of  toluol  (toluene,  Merck).  The  contents  of  the 
tubes  are  then  mixed  by  inverting  several  times.  The 
tubes  are  next  placed  in  a  water-bath  (an  incubator  may  be 
used)  at  37°  C.  for  24  hours. 

At  the  expiration  of  the  incubation  period,  the  test- 
tubes  are  removed  from  the  water-bath.  Clean  test-tubes 
of  10  cc.  capacity  and  numbered  to  correspond  with  the 
gastric  extracts  tested,  as  well  as  the  controls,  are  set  in 
racks.  Into  each  of  these  tubes  is  measured  by  means  of  a 
graduated  pipet,  2  cc.  of  the  glycyltryptophan-gastric- 
extract  mixture  lying  below  the  toluol  in  the  recently 
incubated  tubes.  To  each  tube  are  then  added  3  drops 
of  a  3  per  cent,  glacial  acetic  acid  in  distilled  water  solution. 
The  tubes  are  well  shaken.     Bromine  vapor  is  allowed  to 


EXAMINATION    OF    GASTRO-INTESTINAL    FUNCTION      233 

flow  in  each  tube  until  it  appears  amber-yellow  above  the 
contained  fluid.  The  tubes  are  again  shaken.  Examina- 
tion by  daylight  (preferred)  or  by  white,  artificial  light  is 
now  made  for  evidences  of  the  characteristic  rose-pink 
reaction  between  the  amino-acid  (tryptophan)  and  the 
bromine. 

Tryptophan  Test. — -As,  suggested  by  Weinstein,  this  is 
made,  as  routine,  on  the  fresh  gastric  extracts,  inasmuch  as 
occasionally,  swallowed  saliva,  amino-acids,  regurgitated 
duodenal  contents  and  the  like  may  give  the  bromine 
vapor  reaction,  before  incubation  or  without  the  addition 
of  a  dipeptid  such  as  glycyltryptophan.  Five  cc.  of 
each  fresh,  filtered  gastric  extract  are  poured  into  test- 
tubes  of  10  cc.  capacity  acidulated  with  the  3  per  cent, 
acetic  acid  solution  and  treated  with  bromine  vapor  as 
above.  If  no  characteristic  rose-pink  color  results,  the 
tubes  are  incubated  with  the  corresponding  specimens  that 
have  been  mixed  with  glycyltryptophan  solution.  For 
accurate  work  it  has  seemed  best  to  us  to  cover  these 
''tryptophan  test"  contents  with  a  layer  of  toluol.  At  the 
end  of  12,  24  and  48  hours,  note  is  made  of  changes  in  color, 
and  these  results  are  compared  with  those  obtained  with 
the  preparations  in  the  first  series. 

Certain  precautions  taken  in  the  manipulation  of  the 
reaction  might  be  mentioned  briefly.  All  glassware  was 
boiled  in  distilled  water  and  dried  before  using.  The 
solution  of  glycyltryptophan  employed  was  obtained,  in 
bulk  and  unopened,  direct  from  the  makers.  To  guard 
against  its  tendency  to  crystallize  out  in  cold  solution, 
the  preparation  was  kept  in  a  water-bath  at  37°  C.  until 
used.  All  gastric  extracts  were  carefully  filtered  be- 
fore testing,  and  the  tests  were  set  up  within  2  hours,  at 
the  outside,  from  the  time  the  contents  were  taken  from 
the  patients.  In  testing  for  tryptophan,  before  or  after 
incubation,  bromine  vapor  was  preferred  over  bromine 
water.  It  is  more  readily  controlled  quantitatively  and 
permits  of  better  color  determination.  All  end  reactions 
were  read  by  daylight. 


234 


CANCER   OF   THE    STOMACH 


Typical  Reactions. — When  bromine  vapor  is  used  for  the 
detection  of  amino-acid  (tryptophan),  its  presence  is  indi- 
cated, even  in  small  amounts,  by  lilac-violet  to  rose-pink 
shades.  The  color  is  usually  a  lively  one,  and  appears 
quickly.  Admixtures  of  much  blood  and  bile  produce, 
respectively,  dirty,  brownish-yellow  and  muddy  green 
to  drab.  In  such,  gradations  in  shade  are  impossible. 
High  organic  acidity  often  gives  rich  purple  or  magenta 
hues.  When  the  color  change  is  opalescent,  with  bluish 
or  delicate  lilac  cast,  the  results  may  be  classed  safely  as 
negative. 

Results. — The  gross  results  of  our  observations  are  as 
follows:  Of  1,175  gastric  extracts  from  individuals  with 
gastric  symptoms,  clinically,  110,  or  9.36  per  cent.,  were 

Table  18 


Diagnosis 


Number 
of  cases 


Diagnosis 


Number 
of  cases 


Carcinoma  ventriculi 

Ulcus  ventriculi 

Carcinoma  of  the  liver. . . . 

Ulcer  of  duodenum 

Non-malignant  pyloric  ob- 
struction   

Cholecystitis 

Gall-stones 

Hypochlorhydria 

Achlorhydria 


31 
9 
3 
3 

1 

11 

6 

7 
11 


Achylia  gastrica 

Appendicitis 

Primary  anemia 

Syphilis — stomach 

Various  (gastritis,  gastric 
neurosis,  chronic  diarrhoea, 
epilepsy 


Total. 


10 


110 


Summary  of  Cases  giving  Positive  Glycyltryptophan  Test. — (Author.) 

Table  19 


Diagnosis 

Number 
of  cases 

Diagnosis 

Number 
of  cases 

Carcinoma  ventriculi 

I 

3 
1 
3 

Appendix  lesions 

1 

Ulcus  ventriculi 

Various    (neuroses,    achlor- 
hydria,  arteriosclerosis) . . 

Total 

Ulcer  duodenum 

Q 

Carcinoma  of  the  liver 

Gall-stones 

24 

Summary  of  Cases  giving  Positive  Tryptophan  Test. — (Author.) 


EXAiVIINATION    OF    GASTKO-IXTESTINAL    FUNCTION      235 


Table  20 


Case 
No. 


Diagnosis 


Total     Free 
acidity    HCl 


Blood 


Bile 


Lactic  ^?sre« 
of  re- 
action * 


acid 


61563  Gall-bladder  infect 

9532  Anemia  (post,  mort.) 

61743  Duodenal  iilcer — opr 

61000  GaU-bladder 

61795  Gastritis  chr 

61857  Carcinoma  stom. — opr 

61802  Gastritis;  chr.  append 

38406  Gall-bladder  infect 

53228  Gastric  neurosis 

61852  Carcinoma  of  stomach 

61910  Carcinoma  of  stomach — opr. 

61812  Epilepsy 

61940  Gastritis — chr 

61862  Gastric  neurosis 

61974  Gastritis — alcoholic 

62100  Carcinoma  of  stomach — opr. 

62171  Carcinoma  of  stom. — opr.  . . 

62086  Gastritis— chr 

62089  Gastric  ulcer. 

62219  Carcinoma  of  stom. — opr.  . . 

62154  Carcinoma  of  stom. — opr.  .  . 

62233  Carcinoma  of  liver — expl.  . . 

62260  Pyloric  obstr.,  non-mahgnant 

62399  Carcinoma  of  stom. — opr.  . . 

53032  Duodenal  ulcer — opr 

62562  Carcinoma  of  gall-bl.  opr.. . . 

62665  Gastric  ulcer 

37124  Carcinoma  of  stom.  recur.  . . 

61072  GaU-stones — opr 

62876  j  Cholecystitis 

62912  Chr.  ap.  opr 

62971  Chr.  ap.  opr 

62977  Ulcer  of  stomach 

63026  Chr.  appendicitis 

63051  Neg.  stom.  ap 

63093  Chr.  diarrh.  stom. — neg 

63129  Stom.  ulcer  and  G.  B. — opr. . 

63130  Chr.  app. — opr 

62699  Cholangitis 

63030  Carcinoma  of  stomach 

63241  Carcinoma  of  stomach — opr. 

63292  Gastric  ulcer 

63197  Multiple  sclerosis 

63335  Duod.  ulcer;  cholecyst 

52034  Recurrent  ca.  of  stomach  . . . 

62876  Syph.  stom 

63506  Gastritis 

63547  Resect,  stom.  ca 

63562  Arteriosclerosis 

63600  Appendicitis — neg 

63616  Appendix  and  G.  B. — opr.  .. 

63653  Ulcer  stom. — opr 

63636  Gall-stones — opr 

63778  Carcinoma  of  stom 

36634  Ulcer  of  stom 

63383  Gall-stones — opr 

64057  Hypochlorhydria 


46 

0 

86 

46 

14 

0 

4 

6 

18 

4 

0 

10 

24 

40 

0 

20 

48 

10 

40 

24 

8 

24 

40 

0 

50 

6 

28 

8 

56 

10 

22 

22 

48 

32 

36 

4 

32 

0 

0 

8 

56 

46 

20 

48 

10 

0 

38 

0 

0 

44 

12 

32 

22 

14 

40 

6 


36 
0 

80 

40 
6 
0 
0 
0 

18 
0 
0 

10 

24 

30 
0 
0 
0 
0 

40 

12 
0 

24 

32 
0 

50 
0 

28 
0 

40 
0 

18 
0 

40 

32 

32 
0 

30 
0 
0 
0 

18 

46 
6 

40 
0 
0 

22 
0 
0 

40 
0 

28 
0 
0 

30 


+ 
+ 
0 
0 

+ 

++ 
+ 

0 

+ 
+ 

++ 
+ 

0 

0 

+. 
+ 

0 
0 

+ 

0 

+  + 

Tr. 

+ 
Tr. 

0 

0 

Tr. 
Tr. 

0 

0 

-f- 

0 

0 

+ 

0 
Tr. 
0 
+ 
+ 
0 
0 

+ 

0 
0 

+ 

0 
0 
0 

Tr. 
0 
+ 
+ 
0 

+ 


0 
0 

+  + 

0 
0 
0 

+ 

0 
0 
0 
0 

+  . 

0 

++  + 
+ 

0 
0 

+  + 

0 

+ 
+ 
+ 

0 

+ 
+ 
+ 

Tr. 

+  + 

+ 
0 

+ 
-t- 

0 
0 
0 
0 
0 
0 

+ 
+ 
+ 

-1- 
0 

+ 
+ 

0 

+ 
+ 

0 
0 

+ 

0 
0 

+  + 


0 

0 
0 
0 
0 
0 

? 

0 
0 
0 

++ 

0 
0 

0 

+ 

+ 

++ 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

? 

0 

0 
0 
0 
0 

+ 

0 
0 

0 


+ 
+ 

+ 

+ 
++ 

+ 

++ 
++ 
++ 

+ 
++ 

+ 

+ 
+++ 

+ 

+ 

+ 

+ 

+ 

++ 
++ 

+ 

+ 

+ 

+ 
+  + 

+ 

+ 
+++ 

+ 

+ 

+ 

+ 

+ 

+ 

0 

+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 


236 


CANCER   OF   THE    STOMACH 

Table  20 — (Continued) 


Case 
No. 


64039 
61915 

64270 
64330 
64360 
64482 
64455 
64281 
34078 
64877 
65179 
65229 
65293 
65337 
37889 
65693 

22528 
65703 
65835 
65901 
5231 
65953 
66017 
66108 
66225 
64942 
66314 
66333 
66409 
66462 
56586 
66466 
63547 
66511 
66583 
66644 
66787 
66904 
66855 
66864 
67000 
45833 
67110 
67112 
67077 
67206 
67295 
67368 
67690 
67298 
67562 
67537 


Diagnosis 


Total 
acidity 


Free 
HCl 


Blood 


Bile 


Lactic 
acid 


Achlorhydria 

Hypochlorhydria 

Ulcer  of  stom. — opr 

Carcinoma  of  stomach 

Neurosis 

Care,  of  stom. — resect 

Hypochlorhydria 

Achylia  gastr 

Neuroses 

Cholecystitis 

Appendicitis 

Ca.  of  stom.  and  liver 

Achlorhydria 

Cholecystitis,  appendix 

Appendicitis — opr 

GaU-stones,   and    appendix- 

opr 

Duod.  ulc. — opr 

Degen.  gast.  ulc 

Gen.  care.  prim.  stom. . ; . . .  . 

Carcinoma  of  stom 

Achlorhydria 

Achlorhydria 

Carcinoma  of   stom.  ....... 

Gall-stone — opr 

Pernicious  anemia 

Second,  anemia 

Cholecystitis 

Gall-stones, — opr 

Achlorhydria 

Gastric  ulcer 

Carcinoma  of  stom. — recur.. 

Achlorhydria 

Carcinoma  of  stom. — resect.. 

Achlorhydria 

Cholecystitis 

Carcinoma  of  stom 

Achlorhydria 

Achlorhydria 

Carcinoma  of  stom. — opr.. . . 

Hypochlorhydria 

Deg.  gast.  ulc 

Hypochlorhydria 

Cancer  of  stomach 

Gastric  neurosis , 

Care,  of  liver  and  spleen 

Carcinoma  of  stom , 

Hypochlorhydria 

Carcinoma  of  stom 

Pernicious  anemia 

Carcinoma  of  stom.  P.A.  (?). 

Gall-stone — opr 

Expl.  carcinoma  of  stom 


0 

4 

50 

14 

54 

8 

4 

0 

42 

4 

36 

0 

8 

16 

12 

38 


12 
30 

8 
40 
10 
30 
10 
20 
26 
48 
48 
12 

4 
50 
12 
20 
34 
26 
12 
26 

8 
20 
38 
80 
14 
18 
50 

4 
14 
12 
20 


0 
4 

46 
0 

50 
0 
0 
0 

40 
0 

26 
0 
0 
0 

12 

14 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

30 
0 
0 

26 

48 
0 
0 
0 

50 
0 
0 
0 

26 

12 

26 
8 
0 

24 

80 
0 
8 

50 
0 
0 
0 
0 


0 
0 

+ 
+ 

0 

+ 

+ 
+ 

0 
0 
0 

+ 

0 

0 

Tr. 

24 
0 
0 
0 
+ 
0 
0 

+ 

0 

+ 

0 
0 

+ 
+ 
+ 

0 

0 
Tr. 

0 

0 

0 
Tr. 
Tr. 

+ 

+ 

+ 

+ 

+ 

0 

0 

0 
Tr. 

+ 

0 

+ 

0 

0 


0 
0 
0 
0 

+ 

0 
0 
0 
0 
0 

Tr. 
0 
+ 

Tr. 
0 


+ 

0 

0 

0 

0 

0 

0 

0 

0 

0 

+ 

0 

+ 

0 

0 

0 

+ 

0 

0 

0 

0 

0 

+ 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

+ 

0 

0 

0 

0 

+ 

0 

+ 

0 

0 

0 

+ 

0 

0 

0 

0 

0 

0 

0 

Degree 
of  re- 
action * 


+ 
+ 

+ 

+ 
+ 
+ 

+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 


Clinical  and  Laboratory  Data  of  the  Cases  Returning  Positive    Glycyltryptophan   Test 
(Author') . 

*  Degree  of  reaction:  Lilac  equals  +;  rose-pink  equals  +-1-;  rose-purple  equals  -l--f  4-. 


EXA^IIXATIOX    OF    GASTRO-IXTESTIXAL    FUXCTIOX      237 

glycyltryptophan  positive.  In  the  same  cases.  24.  or 
2.0-i  per  cent,  were  tr^-ptophan  positive,  either  before  or 
after  incubation.  Tables  18  and  19  show,  respectively, 
the  number  of  positives  with  each  test,  associated  with 
different  diseases.  Tables  20  and  21,  respectively,  con- 
sider the  clinical  and  laboratory  data. 

It  will  be  noted  that  one  of  the  valuable  features  of 
the  tables  is  the  fact  that  the  majority  of  the  cases  ex- 
hibiting positive  reactions  were  treated  sui'gically;  hence, 
the  conclusions  derived  from  consideration  of  the  figm^es 
returned  have  a  fahly  definite  pathologic  basis. 

Tahle  21 


No. 


Diagnosis 


Total     Free 
acidity    HCl 


Blood 


BUe 


Lactic 
acid 


Degree 
of  re- 
action* 


67644  Achlorhydria 4 

61508  Stom.  neg j  36 

61496  Duod.  ulcer — opr 56 

61567  :  Gastric  ulcer 42 

61552  Carcinoma  of  stom. — inop .  .  38 

62223  CarcLQoma  of  liver  and  G.B.  24 

62784  Gastric  \ilcer — clin 12 

62876  Achlorhydria  and  G.B 10 

62865  Appendix,    chronic 24 

63051  Gastric  neurosis 36 

63230  Carcinoma  of  stom.  (mass)  . .  8 

63241  Care,  of  stomach  (resect.) —  58 

63221  GaU-stone  empyema  G.B 20 

63414  Duodenal  ulcer — opr 80 

63408  Carcinoma  of  stom. — opr ...  66 

63653  Gastric  ulcer — clin, 32 

63354  Tabes — crises 4 

63563  Arteriosclerosis — gen 0 

63536  GaU-stone— opr 22 

64394  Duodenal  ulcer— opr 66 

64294  Carcinoma  of  stom. — opr.  .  .  14 

65693  Gall-stones  and  append — opr.  38 

5231  Gastric  ulcer  degen.  post-opr.  8 

56586  Carcinoma  of  stom. — recur. .  48 

67112  1  Gastric  neurosis 3S 


0 

0 

36 

0 

38 

0 

20 

0 

18 

-f 

24 

-j- 

12 

4- 

0 

_!_ 

18 

Tr. 

32 

0 

0 

0 

18 

-{- 

20 

0 

80 

0 

60 

0 

28 

Tr. 

0 

-f- 

0 

0 

0 

0 

60 

0 

4 

— 

14 

■b 

0 

0 

0 

0 

24 

0 

0 
0 

Tr. 

0 
0 
0 

0 
0 
0 
0 
0 


CUnical  and  Laboratory    Data    of    the    Cases    Eeturiiiiig     Positive     Trj-ptophan    Test 
(Author) . 

'^  Degree  of  Reaction:  Lilac  equals  —  ;  Rose-pink  equals  —  — ;  rose-purple  equals  -r-r  +  . 


Cancer. — The  total  number  of  proven  cases  of  cancer 
of  the  stomach,  primary  or  secondary,  in  this  series  is  87. 


238  CANCER  OF  THE  STOMACH 

Of  this  number,  31  or  35.6  per  cent.,  gave  positive  gly- 
cyltryptophan  tests,  while  7,  or  8.04  per  cent,  were  tryp- 
tophan positive.  Of  the  31  cases  of  cancer,  in  which 
the  giycyltryptophan  test  was  positive,  the  tryptophan 
test  was  positive  but  7  times.  In  3  cases  in  which  the 
tryptophan  test  was  positive,  the  giycyltryptophan  test 
was  negative. 

Of  9  gastric  ulcers  with  fair  evidence  of  carcinomatous 
degeneration  (of  the  type  described  by  MacCarty),  two, 
or  22.2  per  cent.,  gave  the  giycyltryptophan  reaction.  In 
these  same  cases  there  was  no  positive  tryptophan  test. 
If  we  combine  the  returns  from  these  cases  with  those 
from  the  specimens  of  advanced  carcinoma,  we  noted  that 
the  giycyltryptophan  test  is  positive  in  39.09  per  cent,  and 
the  tryptophan  in  7.28  per  cent.,  or  the  giycyltryptophan 
test  is  positive  approximately  5}i  times  as  frequently  as  is 
the  tryptophan  test. 

Gastric  Ulcer. — In  none  of  35  operated  gastric  ulcers 
(microscopically  carcinoma-free)  was  the  giycyltryptophan 
test  positive.  The  tryptophan  reaction  was  obtained 
once. 

Thirty-nine  cases  were  clinically  diagnosed  as  gastric 
ulcer.  Three  of  these  (7.4  per  cent.)  were  glycyltrypto- 
phan-positive,  and  two  (5.2  per  cent.)  were  tryptophan- 
positive. 

Duodenal  Ulcer. — Operations  were  performed  on  78 
patients  with  duodenal  ulcers.  Of  this  number,  three  (2.6 
per  cent.)  gave  giycyltryptophan  and  tryptophan  tests. 
They  were  not  identical  cases  and  the  reactions  were  not 
always  associated  with  low  acidity. 

Fifty-seven  individuals  had  duodenal  ulcer,  clinically. 
One  (1.7  per  cent.)  was  glycyltryptophan-positive.  None 
gave  the  tryptophan  test. 


EXAMINATION    OF    GASTRO-INTESTINAL   FUNCTION     239 


Table  22 


Group 


Number     Number 
of  posi-      of  nega- 
tives tives 


Group 


Number  }  Number 
of  posi-  j  of  nega- 
tives     !     tives 


Extracts  having  no 
acidity 

Extracts  having  no 
free  Hcl 

Extracts  having  di- 
minished Hcl 

Extracts  having  nor 
mal  Hcl 

Extracts  having  in- 
creased Hcl 


14 
52 
15 
22 


Totals. 


20 

31 

214 

369 

431 


Extracts  having  de- 
creased T.  A 

Extracts  having 
normal  T.  A 

Extracts  having  in- 
creased T.  A 

Totals 


88 

17 

5 

110 


515 

213 

337 

1,065 


Extracts        having 
lactic  acid 


11 


33 


110        1,065 


The  Relation  of  Gj^lcyltryptophan  Test  to  Acidity. — (Author.) 

Other  Gastric  Conditions. — It  has  been  advanced  by 
Weinstein,  Warfield  and  Sanford  and  Rosenbloom  that 
positive  glycyltryptophan  reactions  are  usually  obtained 
in  gastric  extracts  exhibiting  achylia  or  low  hydrochloric 
acid.  These  reactions  are  claimed  to  result  from  the 
presence  of  a  peptid-splitting  enzyme  (Warfield)  existing  in 
saliva.  Gies  thinks  that  mouth-bacteria  may  be  capable 
of  splitting  simple  peptids  under  these  conditions.  In 
order  to  determine  the  results  in  our  cases  from  the  view- 
point of  acidity,  we  have  compiled  Tables  22  and  23.  It 
will  be  seen  that  about  60  per  cent,  of  the  positive  glycyl- 
tryptophan tests  were  obtained  from  extracts  showing  no 
free  hydrochloric  acid,  while  in  an  additional  13.6  per 
cent.,  the  free  hydrochloric  acid  was  low.  In  other  words, 
nearly  three-fourths  of  the  positives  occurred  in  gastric 
extracts  showing  diminished  acidity.  Table  22  also  brings 
out  the  interesting  fact  that  approximately  80  per  cent,  of 
the  glycyltryptophan  reactions  were  returned  by  contents 
in  which  the  total  acidity  was  low. 

The  support   which   these   figures   apparently   give   to 


240 


CANCER   OF   THE    STOMACH 


Warfield's  saliva  ferment  action  on  peptids  is  qualified 
when  one  considers  the  negative  glycyltryptophan  tests  in 
Table  22.  Fifty-one  of  these  extracts  showed  no  free 
hydrochloric  acid.  In  214  extracts  the  free  hydrochloric 
content  was  diminished.  The  combination  of  these  results 
demonstrates  that  about  one-fourth  (24.8  per  cent.)  of  the 
negatives  were  associated  with  low  free  hydrochloric  acid. 
It  could  scarcely  be  maintained  that  all  these  extracts  were 
saliva-free.  Table  20  shows  that  some  of  the  extracts 
were  from  cancerous  patients.  Approximately  one -half 
(48.3  per  cent.)  of  the  negative  glycyltryptophan  tests  were 
on  extracts  with  diminished  total  acidity. 


Table  23 

Group 

Number 
of  posi- 
tives 

Number 
of  nega- 
tives 

Group 

Number 
of  posi- 
tives 

Number 
of  nega- 
tives 

Extracts  having  no 
acidity 

Extracts  having  no 
free  Hcl 

1 
6 
10 
4 
3 

33 

77 
219 
387 

435 

1 

Extracts  having  de- 
creased T.  A 

Extracts  having 
normal  T.  A 

Extracts  having  in- 
creased T.  A 

Totals 

Extracts        having 
lactic  acid 

17 
2 
5 

586 

228 

Extracts  having  di- 
minished Hcl 

Extracts  having  nor- 
mal Hcl 

337 

24 

1,151 

Extracts  having  in- 
creased Hcl 

2 

42 

Totals 

24 

1,151    1 

The  Relation  of  Tryptophan  Test  to  Acidity. —  (Author. J 

A  consideration  of  the  relation  of  the  tryptophan  test 
to  acidity  is  of  interest.  Of  the  positives  7,  or  28.9  per 
cent,  of  the  contents  contained  no  free  hydrochloric  acid. 
In  17  (75  per  cent.)  of  the  positives  the  free  hydrochloric 
acid  was  diminished  or  absent.  This  combined  figure  is 
practically  identical  with  that  returned  by  the  glycyltrypto- 
phan positives,  although  the  percentage  of  extracts  con- 


EXAMINATION    OF    GASTRO-INTESTINAL    FUNCTION      241 

taining  no  free  acid  is  mucli  lower.  In  the  tryptophan 
positives  it  will  be  seen  that  75  per  cent,  showed  diminished 
total  acidity  as  against  SO  per  cent,  in  the  case  of  glycyl- 
trj'ptophan  positives  (Table  23). 

Studying  the  negative  tr^-ptophan  reactions,  we  note 
that  in  329  instances  ''28.6  per  cent.)  there  was  absent  or 
diminished  free  acid,  while  in  586  cases  (50.8  per  cent.)  the 
total  acidity  was  low.  These  figm'es  closely  approximate 
those  shown  by  the  tabulations  from  the  negative  gly- 
cyltryptophan  reactions. 

It  would  appear  that  Weinstein's  contention  that  his 
tryptophan  test  removes  the  consideration  of  contaminat- 
ing sahva  as  a  source  of  error  is  not  borne  out  by  our 
study.  Further,  the  presence  of  negative  glycyltryptophan 
reaction,  in  so  large  a  percentage  of  extracts  with  low 
acidity,  leads  one  to  the  opinion  that  the  significance  of 
the  peptidase,  said  to  exist  in  sahva,  as  a  factor  in  hycko- 
lyzing  glycyltr^-ptophan  added  to  gastric  extracts,  is  quite 
Cj[uestionable.  This  opinion  is  substantiated  by  our  work 
on  saUva.     (Arch.  Int.  Med.,  Dec,  1912,  p.  1.) 

Organic  Acid. — -Ten  per  cent,  of  the  positive  glycyltryp- 
tophan tests  were  associated  with  the  presence  of  lactic 
acid.  TVith  the  exception  of  one,  the  cases  were  carcinoma. 
Thnty-three  negative  reactions  (3.9  per  cent.)  were  in 
contents  containing  lactic  acid.  Eight  and  one-third  per  cent, 
of  the  positive  tryptophan  tests  were  present  in  lactic-acid- 
containing  extracts,  while  -12  ('3.6  per  cent.)  negative 
tryptophan  contents  contained  lactic  acid.  It  would 
seem  that  organic  acids  have  little  bearing  on  the  relative 
variation  of  the  two  tests. 

Of  the  entire  number  of  gastric  extracts  ('1,175)  analyzed 
in  this  series,  44,  or  3.7  per  cent.,  contained  lactic  acid  by 
the    controlled    L'ffelmann    test.     Of    the    cases    proved 

16 


242 

CANCEK   OF   THE    STOMACH 
Table  24 

(A)  The  relation  of  bile  to  glycyl- 
tryptophan test 

(B1  The  relation  of  bile  to  tryptophan 
test 

Groups 

Bile 
present 

Bile 
absent 

Groups 

Bile 
present 

Bile 

absent 

Glycyltryptophan 
positive 

Glycyltryptophan 
negative 

39 
320 

71 

745 

Tryptophan 
tive 

Tryptophan 
tive 

Totals. 

posi- 
nega- 

10 

349 

14 
802 

Totals 

359 

816 

359         816 

The  Influence  of  the  Presence  of   Bile  upon  the  Glycyltryptophan  and 
the  Tryptophan  Tests — (Author). 

to  be  carcinoma  ventriculi,  lactic  acid  was  present  in  25 
(28.7  per  cent.).  As  we  have  shown  in  these  cases,  the 
glycyltryptophan  reaction  was  positive  in  31  (35.6  per 
cent.)  and  the  tryptophan  tests  in  7  (8.04  per  cent.). 
The  relatively  low  percentage  of  extracts  containing  lactic 
acid  may  be  explained  on  the  basis  of  early  diagnosis, 
many  cases  being  operated  on  before  marked  obstruction 
and  retention  had  developed.  Emerson  states  that 
in  his  series  of  cases  of  carcinoma  ventriculi,  lactic  acid 
was  present  in  approximately  90  per  cent.  From  our 
experience,  it  would  appear  that  the  great  majority  of  his 
cases  were  far  advanced,  and  exhibited  marked  retention. 
High  mixed  organic  acidity  frequently  gives  confusing 
U-ffelmann  reactions. 

It  has  been  held  that  the  chyle  in  gastric  extracts  viti- 
ates the  glycyltryptophan  test,  but  need  not  be  considered 
when  making  the  tryptophan  test.  The  presence  of  bile  or 
evidences  of  tryptic  digestion  has  been  used  as  proof  that 
duodenal  contents  have  been  mixed  with  gastric  juice. 

The  significance  of  this  supposition  is  shown  by  analysis 
of  Table  24.  The  gastric  extracts  were  judged  macro- 
scopically  as  to  the  presence  of  bile,  and  were  also  tested 


EXAMINATION   OF   GASTRO-INTESTINAL   FUNCTION      243 


by  means  of  the  Pettinkofer  or  the  fuming  nitric  acid  reac- 
tion. It  will  be  seen  (a)  that  of  110  positive  glycyltryp- 
tophan  reactions,  39  (35.4  per  cent.)  contained  bile;  of 
1,065  negative  reactions,  320  (20.4  per  cent.)  showed  bile; 
of  the  24  positive  tryptophan  tests;  (6)  10  (41.6  per  cent.) 
were  in  bile-containing  extracts,  while  349  (30.4  per  cent.) 
negative  tryptophan  tests  were  bile  positive.  These  fig- 
ures do  not  demonstrate  that  the  tryptophan  test  is  un- 
influenced by  chyle  in  the  extracts.  It  is  worthy  of  note 
that  a  relatively  high  number  of  both  glycyltryptophan 
and  tryptophan  reactions  are  found  in  bile-containing 
chyme. 

Table  25 


(A)   The  relation  of  blood  to  glycyl- 
tryptophan test 


Groups 


Bile 
present 


BUe 

absent 


(B)   The  relation  of  blood  to  tryptophan 
test 


Groups 


Bile 
present 


Bile 
absent 


Glycyltryptophan 
positive 

Glycyltryptophan 
negative 


Totals. 


56 

54 

236 

829 

292 

883 

Tryptophan      posi- 
tive          10 

Tryptophan     nega- 


tive   

Totals . 


282 


292 


14 

869 


883 


The  Influence  of  Blood  upon  the  Glycyltryptophan  and  the  Tryptophan 
Tests— (Author). 


The  effect  of  blood,  traumatic  or  ''occult,"  in  gastric 
extracts  has  at  least  two  points  worthy  of  consideration  with 
regard  to  the  glycyltryptophan  and  tryptophan  tests. 
Traumatic  blood  of  itself  gives  a  tan  or  definitely  red  cast 
to  filtrates.  A  color  reaction  such  as  we  are  discussing  is 
readily  affected  by  such  shades.  The  second  point  of  note 
is  the  possibility  of  tryptophan  resulting  from  split  diges- 
tion products  of  the  blood  itself,  particularly  in  those  cases 
in  which  there  is  marked  gastric  retention  with  much  flora. 


244  CANCEK  OF  THE  STOMACH 

Table  25  furnishes  interesting  data  on  the  above  points. 
In  56  (50.9  per  cent.)  of  the  glycyltryptophan  positive  ex- 
tracts, blood,  traumatic  or  altered  (benzidin  test),  was 
present.  Of  the  glycyltryptophan  negative  extracts,  in 
236  (22  per  cent.)  blood  was  demonstrated.  Of  the 
tryptophan  positive  extracts  10  (41.6  per  cent.)  contained 
blood.  In  282  (24.6  per  cent.)  tryptophan  negatives, 
blood  was  proved.  These  figures  for  both  tests  so  closely 
approximate  that  it  does  not  seem  possible  to  state  that 
advantage  lies  with  either.  The  relatively  high  percent- 
age of  positives  in  extracts  containing  blood  should,  how- 
ever, be  borne  in  mind. 

Summary. — 1.  In  our  series,  more  than  one- third  of  the 
proved  cases  of  cancer  of  the  stomach  gave  positive 
glycyltryptophan  reactions;  more  than  one-fourth  were 
lactic-acid  positive  and  about  one-thirteenth  of  the  number 
exhibited  the  tryptophan  test.  Diagnosis  of  malignant 
disease  of  the  stomach  was  in  each  case  quite  possible 
independent  of  the  above  chemical  reactions.  As  a 
test  associated  with  cancer  of  the  stomach,  it  will  be  seen 
that  in  our  series  the  glycyltryptophan  reaction  proved 
more  consistent  than  test  for  existing  free  amino-acid 
(tryptophan) . 

2.  While  gastric  conditions  other  than  cancer  exhibit 
positive  glycyltryptophan  reactions,  in  no  single  class  of 
disease  of  the  stomach  is  this  test  obtained  so  frequently 
as  in  cancer.  This  fact  is  of  considerable  significance 
chemically,  and,  perhaps,  etiologically.  While  cancer  of 
the  stomach  can  doubtless  be  diagnosticated  clinically 
without  the  glycyltryptophan  test,  one  cannot  state  that 
the  study  of  this  and  allied  reactions  will  prove  valueless. 

3.  Our  work  does  not  show  that  the  tryptophan  test 
is,  as  has  been  advanced,  pathognomonic  of  cancer. 


EXAMINATION   OF    GASTRO-INTESTINAL   FUNCTION     245 

4.  Low  free  hydrochloric  or  total  acidity  is  frequently 
determined  in  gastric  contents  exhibiting  positive  gly- 
cyltryptophan,  lactic  acid  and  tryptophan  reactions. 
One  cannot  state  positively  that  this  diminished  acidity 
is  causative.  Many  cases  of  low  acidity  were  negative  to 
the  above  tests. 

5.  Approximately  one-half  of  the  positive  glycyltryp- 
tophan  and  tryptophan  reactions  were  in  gastric  extracts 
containing  bile  and  blood  elements.  Approximately  one- 
fourth  of  the  negative  extracts  contained  blood  and  bile 
elements. 

Wolff- Junghans'  Test  for  Soluble  Albumin.— Methods 
for  the  estimation  of  the  soluble  albuminous  products 
of  digestion  have  frequently  been  devised  with  the  hope 
that  such  might  prove  of  practical  service  in  the  dif- 
ferential diagnosis  of  gastric  ailments.  Of  these  methods, 
the  well-known  procedure  advanced  by  Salomon  had  for  a 
time  the  greatest  vogue.  Esbach's  reagent  and  tubes 
proved,  however,  unsatisfactory  and  inaccurate  from  a 
clinical  viewpoint.  More  recently  the  problem  has  been 
approached  from  the  practical  quantitative  side  and 
encouraging  work  recorded. 

Wolff  and  Junghans  report  a  method  for  estimation  of 
the  amount  of  soluble  albumin  in  gastric  extracts  which 
they  claim  have  given  excellent  clinical  information  in 
Ewald's  service  at  the  Augusta  Hospital,  Berlin. 

Theoretically,  their  procedure  has  the  following  basis: 
In  the  normal  aspirated  test-meal  there  are  demonstrable 
relatively  large  quantities  of  soluble  albumin  by  means  of 
precipitating  reagents.  This  soluble  albumin  appears 
only  through  the  agency  of  the  gastric  enzymes.  This 
fact  is  proved  by  testing  for  soluble  albumin  a  similar 
test-meal  which  has  been  chymified  but  not  swallowed.     In 


246  CANCER   OF   THE    STOMACH 

such  event,  only  minute  quantities  of  dissolved  albumin 
are  present. 

Acting  on  these  observed  facts,  Wolff  and  Junghans  fed 
similar  meals  to  sets  of  individuals  revealing  malignant  and 
benign  ach3dias.  Their  work  appeared  to  show  that  in  the 
malignant  achylias,  aspirated  test-meals  were  rich  in 
soluble  albumin,  while  in  benign  achylias  very  little  of  the 
albumin  could  be  demonstrated. 

Three  suppositions  have  been  advanced  to  explain  this 
increased  volume  of  dissolved  albumin  in  the  malignant 
achyhas.  It  has  been  suggested  that  the  excess  of  albumin 
is  due  (a)  to  interference  with  albuminous  resorption;  (6) 
to  a  ''cancer  milk"  rich  in  albumin  which  exudes  from 
mahgnant  growths,  and  (c)  to  a  specific,  peptid-splitting 
ferment  from  the  neoplasm,  capable  of  carrjdng  protein 
digestion  as  far  as  the  completely  soluble  albumin  stage. 

Clinically,  the  reaction  was  shown  to  be  positive  in  18 
of  a  series  of  20  gastric  cancers  and  negative  in  14  of  a 
series  of  15  cases  of  simple  achylia  in  Ewald's  service. 
Recently,  Rolph  has  reported  positive  tests  in  all  of  7 
cases  where  cancer  was  present  in  the  stomach  or  second- 
arily involved  that  viscus.  In  8  cases  of  benign  achyUa 
the  test  proved  negative.  Rolph  states  that  gastric 
contents  contaminated  with  blood  beyond  a  dilution  of  1 
to  3,000  may  give  the  reaction  and  cautions  against  positive 
interpretation  in  instances  where  there  is  high  combined 
acid  present.  In  such  event  peptone  is  usually  present. 
He  claims  that  cancer  of  the  cardia  is  not  so  Likely  to 
give  positive  reaction  as  is  cancer  in  other  parts  of  the 
stomach. 

Author's  Study. — In  the  last  3,950  patients  presenting 
themselves  for  test-meal  examination  of  gastric  function 
in  his  service  at  the  Mayo  Clinic,  three  were  747  instances 


exa:\iixatiox  of  gastro-ixtestixal  fuxctiox    247 

where  gastric  extracts  showed  achyUa  or  were  associated 
with  conditions  confusable  with  malignancy.  These 
gastric  extracts  were  all  tested  by  him  for  soluble  albumin 
by  the  Wolff -Junghans"  method.  Records  were  kept  of 
the  association  of  the  results  of  this  test  with  other  test- 
meal  and  clinical  findings.  When  the  tabulations  were 
com.pleted  the  diagnoses  were  entered  on  the  daily  sheets. 
In  78.4  per  cent,  of  cases  it  was  possible  to  obtain  check 
upon  diagnoses  by  operation. 

Preparation  for  Test — The  day  previous  to  the  examina- 
tion of  his  gastric  extract  the  patient  was  given  1  ounce  of 
castor  oil  at  4  p.m.  This  was  followed  at  6  p.m.  by  a 
motor  test-meal  consisting  of  mixed  food.  At  7  p.m. 
twenty  raw.  seedless  raisins  were  given.  Twelve  hours 
later  (7  a.m.  the  following  morning)  the  patient  was  fed 
60  grams  of  second-day  bread  and  200  cc.  of  water.  This 
secretory  test-meal  was  removed  from  50  to  60  minutes 
after  administering.  The  specimen  secured  was  thor- 
oughly mixed,  filtered  through  double  hydrochloric-acid- 
washed  papers,  and  tested  for  dissolved  albumin  within 
an  hour  of  its  being  obtained  from  the  stomach.  On 
account  of  the  fact  that,  as  had  been  shown  in  this  chnic, 
but  52.2  per  cent,  of  cases  of  gastric  cancer  jdeld  gastric 
extracts  reveahng  absence  of  free  hydrochloric  acid,  and 
that  in  15.7  per  cent,  of  cases,  free  hydrochloric  acid 
ranges  between  20  and  50  per  cent.,  we  deemed  it  ad- 
visable to  apply  the  test  for  soluble  albumin  not  only  to 
achyhas  but  also  to  gastric  extracts  where  the  free  hy- 
drochloric acid  was  below  20  per  cent.  In  a  few  instances 
of  suspected  mahgnant  ulcer  we  have  performed  the  test 
upon  gastric  extracts  with  higher  free  hydi^ochloric  acid 
content.  In  such  we  have  been  fully  alive  to  the  possi- 
bilities of  error,  but  for  the  purpose  of  gaining  informa- 


248  CANCER   OF   THE    STOMACH 

tion  and  for  comparison  we  have  deemed  it  wise  to  make 
the  test. 

Mode  of  Procedure. — Six  absolutely  clean  test-tubes  are 
required  for  each  test.  Those  of  the  narrow  type  and  of 
20  cc.  capacity  answer  very  well.  The  tubes  are  numbered 
serially  from  1  to  6.  They  receive  respectively  1  cc, 
0.5  cc,  0.25  cc,  0.1  cc,  0.05  cc  and  0.025  cc  of  the 
filtered  gastric  extract.  These  amounts  are  readily  meas- 
ured by  means  of  a  1  cc  pipette,  graduated  into  Koo's  cc 
By  means  of  a  10  cc  pipette,  graduated  into  Koo's  cc, 
the  volume  in  each  test-tube  is  next  consecutively  brought 
up  to  10  cc.  volume  with  distilled  water.  This  gives  from 
the  tubes  1  to  6  dilutions  of  gastric  juice  varying  re- 
spectively from  1  to  10  to  1  to  400  (viz.,  1  to  10,  1  to  20, 
1  to  40,  1  to  100,  1  to  200,  and  1  to  400).  These  figures 
we  have  termed  ''units"  of  precipitable  albumin.  The 
tubes  are  then  inverted  several  times  to  insure  complete 
mixture  of  their  contents.  One  cc.  of  the  reagent  to  pre- 
cipitate the  albumin  in  solution  is  then  carefully  layered 
upon  the  contents  of  each  tube.  The  precipitating  re- 
agent suggested  by  Wolff  has  proved  satisfactory  with  us. 

It  has  the  following  formula: 

Phosphotungstic  acid  (puriss) 3  cc . 

Hj'drochloric  acid  (concentrated) 10  cc. 

Alcohol  (96  per  cent.) .    200  cc. 

Aq.  dest .q.  s.  ad.   2000  cc. 

Mix  and  keep  in  a  glass  or  rubber-stoppered  flask  in  a  cool  place. 

Manifestation  and  Interpretation  of  the  Test. — If  there 
has  been  dissolved  albumin  in  any  of  the  tubes,  the  junction 
of  the  Wolff  reagent  with  the  diluted  gastric  extracts  is 
marked  by  a  pearly  white  zone  or  ''ring."  This  is  better 
brought  out  if  the  tubes  are  inspected  against  a  black 
background.  (We  have  used  a  piece  of  black  cloth  such 
as  photographers  employ  when  focussing  cameras).     The 


EXAMINATION    OF    GASTRO-INTESTINAL   FUNCTION      249 

tubes  should  be  inspected  at  once  after  adding  the  Wolff 
solution.  Prolonged  standing  allows  cloudy  zones  to  form 
which  render  comparative  interpretation  dubious. 

We  have  interpreted  our  results  after  Wolff  and  Jung- 
hans'  suggestion.  If  the  white  ring  of  precipitated  albumin 
appears  in  tubes  1,  2  and  3  (namely,  units  of  albumin 
from  10  up  to  50)  and  no  further  manifestations  are  present 
in  the  remaining  three  tubes  we  have  called  the  test  negative. 
If  tubes  1,  2,  3  and  4  exhibit  rings  (units  of  albumin  from 
10  to  100)  we  have  considered  the  reaction  suspicious.  The 
presence  of  white  rings  in  tubes  1,  2,  3,  4,  5  and  above  (units 
of  albumin  ranging  from  10  to  200  to  400)  we  have  taken  to 
denote  a  positive  test. 

Results, — The  gross  results  of  our  work  were  as  follows: 
Of  747  gastric  extracts  of  the  class  described  above,  318 
(42.6  per  cent.)  gave  200  to  400  units  of  precipitable 
albumin;  112  (15.7  per  cent.)  exhibited  100  units,  and 
317  (42.4  per  cent.)  showed  less  than  100  units.  In  this 
grouping  71.5  per  cent,  of  the  gastric  extracts  were  from 
cases  showing  some  degree  of  gastric  retention. 

Consideration  of  Cancer  Cases. — There  were  215  cases  of 
operatively  and  pathologically  demonstrated  gastric  car- 
cinoma in  this  series.  In  141  (65.1  per  cent.)  units  of 
precipitable  albumin  ranged  from  200  to  400.  In  29 
instances  (13.4  per  cent.)  there  were  100  units  of  albumin 
shown.  Combining  the  returns  it  is  evident  that  170 
(78.5  per  cent.)  of  the  proved  cases  of  gastric  cancer  gave 
either  undoubtedly  positive  or  suspiciously  positive  Wolff- 
Junghans'  test.  In  45  cases  (21  per  cent.)  the  test  was 
negative,  less  than  100  units  of  precipitable  albumin 
being  demonstrated.  Of  this  group  of  215  cases  of  gastric 
cancer,  73.2  per  cent,  exhibited  some  grade  of  motor 
stagnation. 


250  CANCER  OF  THE  STOMACH 

Gastric  extracts  from  15  cases  of  ulcus  carcinomatosum 
were  tested.  In  11  instances  (73.3  per  cent.)  units  of 
precipitable  albumin  ranged  between  200  to  400.  In  3 
(20  per  cent.)  100  units  were  shown.  In  other  words,  of 
the  15  cases  of  malignant  gastric  ulcer,  14  (93.3  per  cent.) 
were  either  definitely  positive  or  suspiciously  so  to  the 
Wolff-Junghans'  test.  One  case  (6.6  per  cent.)  exhibited 
below  100  units  of  albumin.  In  this  group,  motor  stagna- 
tion of  some  degree  was  present  in  86.6  per  cent. 

Combining  the  results  from  the  cases  of  frank  gastric 
carcinoma  and  those  of  ulcus  carcinomatosum,  it  is  seen 
that  of  a  total  of  230  cases,  184  (80  per  cent.)  returned 
positive  or  suspicious  Wolff-Junghans'  test. 

Relation  of  Manifestations  of  Test  to  Location  of  Malignant 
Process. — ^We  examined  gastric  extracts  from  10  cases 
of  cancer  involving  the  cardia.  Six  cases  (60  per  cent.) 
gave  positive  test,  1  (10  per  cent.)  was  suspicious,  and  3 
(30  per  cent.)  were  negative.  Thus  70  per  cent,  of  our 
cases  of  cancer  at  the  cardia  showed  units  of  precipitable 
albumin  ranging  from  100  to  400. 

There  were  5  cases  of  cancer  of  the  fundus  in  our  series ; 
1  (20  per  cent.)  was  positive,  1  (20  per  cent.)  was  doubtful, 
and  3  (60  per  cent.)  were  negative. 

We  have  records  of  44  cases  where  the  neoplasm  involved 
mainly  the  lesser  curvature  of  the  stomach.  Of  this  group, 
33  cases  (75  per  cent.)  gave  clearly  positive  Wolff-Junghans' 
tests,  4  (9.1  per  cent.)  were  supicious,  and  7  (15.8  per  cent.) 
were  negative.  It  is  evident  that  84.1  per  cent,  of  cancers 
involving  the  lesser  curvature  show  units  of  precipitable 
albumin  ranging  from  100  upward. 

In  our  series  there  were  3  cases  of  cancer  of  the  greater 
curvature.     Two  cases  (66.6  per  cent.)  were  positive  and 


EXAMINATION    OF   GASTRO-INTESTINAL   FUNCTION     251 

the  remaining  case  suspicious.  Thus  all  showed  100  plus 
units  of  albumin. 

Eight  of  our  cases  were  proved  to  have  cancer  involving 
mainly  the  posterior  wall  of  the  stomach.  Of  this  group 
but  3  cases  (37.5  per  cent.)  were  positive  to  the  test,  while  5 
cases  (62.5  per  cent.)  were  negative. 

The  pars  media  was  involved  14  times.  Of  this  number, 
11  cases  (78.5  per  cent.)  gave  positive  tests  and  3  cases  (21.5 
per  cent.)  were  negative. 

In  93  instances  the  malignant  growth  was  at  the  pylorus 
and  antrum.  In  this  class,  59  cases  (63.4  per  cent.) 
showed  units  of  precipitable  albumin  from  200  upward,  8 
cases  (8.6  per  cent.)  were  suspicious,  revealing  100  units, 
and  25  cases  (26.9  per  cent.)  were  negative.  In  other 
words,  72  per  cent,  of  the  cancers  at  the  pyloric  region  gave 
positive  or  suspicious  Wolff-Junghans'  tests. 

Our  series  includes  38  cases  where  the  stomach  showed 
general  or  extensive  malignant  involvement.  In  26  in- 
stances (68.5  per  cent.)  the  test  was  positive,  in  3  cases 
(7.9  per  cent.)  it  was  suspicious,  while  9  times  (23.6  per 
cent.)  negative  results  were  obtained. 

Comparison  of  Other  Test-meal  Findings  in  the  Cancer 
Cases  with  the  Wolff-Junghans'  Test. — It  might  be  profitable 
here  to  emphasize  the  diagnostic  relation  of  other  tests 
associated  with  that  for  dissolved  albumin  in  the  gastric 
extracts  from  our  malignant  cases.  It  will  be  noted  above 
that  of  the  230  cancer  and  malignant  ulcer  cases  the  Wolff- 
Junghans'  test  was  positive  or  suspicious  in  184  (80  per 
cent.).  In  this  same  group  of  cases,  free  hydrochloric  acid 
was  absent,  in  52.2  per  cent.,  lactic  acid  was  demonstrated 
in  48.8  per  cent.,  '^occult"  or  altered  blood  shown  in  75  per 
cent.,  glycyltryptophan  test  present  in  40  per  cent.  (141 
cases),  the  average  formol  index  (method  of  Sorenson  and 


252  CANCER  OF  THE  STOMACH 

Schiff)  was  21  (57  cases),  and  organisms  of  the  Oppler- 
Boas  group  were  demonstrated  in  93.8  per  cent.  (146 
cases)  by  the  colored  agar  method.  Some  degree  of 
gastric  retention  was  shown  in  nearly  74  per  cent,  of  the 
entire  group  of  cancer  cases,  irrespective  of  the  location  of 
the  growth. 

The  Wolff-Junghans^  Test  in  Extragastric  Cancer:  Liver 
and  Gall  Tract. — Our  series  includes  15  instances  of  malig- 
nancy in  these  locations.  In  5  cases  (33.3  per  cent.)  the  test 
was  positive,  in  3  cases  (20  per  cent.)  it  was  suspicious,  and 
in  7  cases  (46.6  per  cent.)  it  was  negative.  Thus  8  cases 
(53.3  per  cent.)  of  extragastric  malignancy  showed  units  of 
albumin  from  100  upward.  Some  degree  of  motor  stagna- 
tion was  evidenced  in  26.6  per  cent,  of  these  cases. 

The  pancreas  was  the  seat  of  malignant  processes  3 
times.  In  no  instance  was  a  positive  Wolff-Junghans'  test 
obtained.     Motor  defect  was  not  noted  in  any  of  these  cases. 

There  was  1  case  of  cancer  of  the  transverse  colon.  It 
gave  a  negative  test.  There  was  normal  gastric  motility  in 
this  case. 

Gastric  Syphilis.- — -We  have  tested  gastric  extracts  for 
dissolved  albumin  from  5  cases.  The  reaction  was  positive 
in  2  instances  (40  per  cent.),  suspicious  in  1  (20  per  cent.), 
and  negative  in  2  (40  per  cent.).  In  one  of  the  positive 
cases  the  specific  process  in  the  stomach  was  associated 
with  multiple  and  exuberant  ulceration.  Gastric  motility 
was  interfered  with  in   1  case  (20  per  cent.)  of  this  group. 

Primary  Anemias  {Mainly  Pernicious). — Twenty-four 
cases  of  achylia  in  severe  anemia  comprise  this  class.  In 
none  of  them  was  gastric  stagnation  present.  Twenty- 
three  (95.6  per  cent.)  of  this  group  were  negative  to  the 
Wolff-Junghans'  test.  In  but  1  instance  (3.3  per  cent.) 
were  the  units  of  perceptible  albumin  above  200. 


EXAMINATION    OF    GASTEO-INTESTINAL    FrNCTION      253 

Simple  Achylia  Gastrica.- — We  examined  gastric  ex- 
tracts from  35  such  cases.  Gastric  stagnation  was  proved 
in  4  cases  (11.9  per  cent.).  In  22  instances  (63  per  cent.) 
of  this  tj^e  of  achylia  the  test  was  negative,  in  9  instances 
(25.9  per  cent.)  suspicious,,  and  positive  but  4  times  (11.9 
per  cent.). 

Ackylorhydria. — In  addition  to  the  cases  of  absent 
free  hych'ochloric  acid  mentioned  in  the  above  groups  there 
were  212  cases  of  non-malignant  cUsease  showing  achylor- 
hydi'ia.  Gastric  motility  was  impahed  in  22  cases  (10.3 
per  cent.).  In  this  group  136  cases  (64.1  per  cent.)  were 
Wolff -Junghans^  negative,  41  cases  (19.3  per  cent.)  were 
doubtful,  and  35  cases  (16.5  per  cent.)  were  positive. 

Simple  Gastric  Ulcer. — A  number  of  cases  of  this  affec- 
tion and  of  duodenal  ulcer  were  stucUed  for  purposes 
of  comparison  with  maUgnant  disease.  Their  gastric 
extracts  generally  showed  low  free  hydrochloric  acid 
content.  We  tested  extracts  from  33  cases  of  operatively 
demonstrated  gastric  ulcer  for  dissolved  albumin.  In 
16  cases  (48.4  per  cent.)  units  of  albumin  ranged  above 
200,  in  6  instances  (18.1  per  cent.)  the  units  ran  as  high  as 
100,  while  in  11  cases  (30.3  per  cent.)  units  of  albumin 
were  below  100.  It  is  thus  apparent  that  66.5  per  cent. 
of  the  proved  cases  of  simple  gastric  ulcer  were  positive 
or  suspicious  to  the  Wolff- Junghans'  test.  Gastric  motiht}' 
was  delayed  in  39.4  per  cent,  of  this  group. 

Duodenal  Ulcer. — Gastric  extracts  from  18  cases  of 
duodenal  ulcer  were  tested.  In  12  cases  (66.6  per  cent.) 
units  of  albumin  ranged  above  200,  in  2  cases  Ql  per 
cent),  at  least  100  units  were  present,  while  4  times  (^22.7 
per  cent.)  less  than  100  units  were  demonstrated.  It  is  thus 
evident  that  78  per  cent,  of  our  cases  of  duodenal  ulcers 
were    Wolff- Junghans'    positive    or    suspicious.     In    this 


254  CANCER   OF   THE    STOMACH 

group,  gastric  stagnation  was  present  in  55.5  per  cent,  of 
the  cases. 

Nephritis  and  Cardiovascular  Disease. — Our  series  in- 
cludes 12  cases  of  cardiorenal  affections  associated  with 
obscure  gastric  complaint  and  anemia.  The  gastric  ex- 
tracts showed  achyha.  In  6  instances  (50  per  cent.)  the 
Wolff-Junghans'  test  was  doubtful,  while  in  an  equal 
number  it  was  negative.  The  doubtful  cases  were  asso- 
ciated with  some  degree  of  gastric  motor  insufficiency. 

Cases  Exhibiting  Low  Gastric  Acidity. — -In  this  group  we 
include  159  instances  where  gastric  acidity  ranged  from 
2  to  70.  The  average  was  18.7.  This  group  furnished 
what  might  be  regarded  as  controls  on  our  reactions  in 
other  groups,  as  well  as  demonstrated  what  results  might 
be  expected  from  the  Wolff-Junghans'  test  in  extragastric, 
maUgnant,  and  non-malignant  ailments.  It  should  be 
emphasized  that  all  of  the  patients  examined  complained 
of  some  gastric  disturbance.  The  finding  of  the  low 
free  hydrochloric  acid  in  some  instances  might  have  led 
to  suspicions  of  malignancy  by  those  who  hold  gastric 
acidity  as  a  strong  index  of  such  condition.  This  might 
have  been  especially  so  when  we  recall  that  the  average 
age  of  our  patients  is  above  40  years. 

Clinically,  this  group  was  varied  as  to  diagnosis.  Among 
the  affections  were  appendicitis,  cholecystitis,  cholelithia- 
sis, alcohoUc  gastritis,  gastric  neuroses,  pulmonary  tuber- 
culosis, tabes,  multiple  sclerosis,  tuberculous  peritonitis, 
nephrolithiasis,  pancreatitis,  cirrhosis  of  the  liver,  preg- 
nancy, malaria,  diabetes,  aneurysm  of  the  abdominal  aorta, 
chronic  constipation,  hemophilia,  cancer  of  the  breast, 
cancer  of  the  lip. 

Of  this  heterogeneous  group  of  low  gastric  acidity  cases, 
40    (25.1    per   cent.)    were   Wolff-Junghans'    positive,    38 


EXAMINATION    OF    GASTRO-INTESTINAL    FUNCTION      255 

(23.9  per  cent.)  were  doubtful,  and  81  (50.9  per  cent.) 
were  negative.  In  other  words,  of  this  class  nearly  50  per 
cent,  of  cases  showed  units  of  precipitable  albumin  from  100 
upward.  Gastric  motility  was  interfered  with  in  some 
degree  in  25  cases  (15.7  per  cent.). 

Relation  of  the  Wolff- Junghans^  Test  to  the  Presence  of 
Blood  in  Gastric  Extracts. — We  have  frequently  tested 
gastric  contents  that  were  discolored  bright  red  by  trau- 
matic blood  without  getting  positive  Wolff- Junghans'  tests. 
Of  our  entire  series  of  747  cases  herewith  detailed,  '' occult" 
blood  was  demonstrated  by  the  benzidin  test  in  43.2  per 
cent.  Reference  to  the  gross  summary  of  our  work  above 
will  reveal  the  fact  that  we  obtained  positive  tests  for  pre- 
cipitable albumin  in  42.6  per  cent,  of  the  gastric  extracts  of 
the  entire  series,  while  in  15  per  cent,  the  test  was  doubtful. 
There  may  be  more  than  a  curious  relationship  between 
these  groups  of  figures. 

Summary. — Our  work  appears  to  justify  the  following 
conclusions : 

1.  When  carefully  performed  and  interpreted  the  Wolff- 
Junghans'  test  for  demonstration  of  dissolved  albumin  in 
gastric  extracts  was  positive  or  suspicious  in  80  per  cent,  of 
our  series  of  gastric  cancer.  In  this  series  it  was  a  more 
constant  finding  in  gastric  extracts  than  were  absent  free 
hydrochloric  acid,  the  presence  of  lactic  acid,  and  the 
glycyltryptophan  test.  It  was  rather  more  constant  than 
tests  for  occult  blood  and  the  demonstration  of  gastric 
motor  inefficiency.  It  was  not  so  consistent  in  its 
manifestation  as  the  demonstration  of  organisms  of  the 
Oppler-Boas  group  or  the  increase  in  the  formol  index. 

2.  In  extragastric  malignancy,  gastric  syphilis,  and 
nephritis  the  Wolff-Junghans'  test  seems  inconstant. 

3.  In  the  differentiation  between  malignant  and  non- 


256  CANCER  OF  THE  STOMACH 

malignant  achylias  the  Wolff-Junghans'  test,  when  inter- 
preted in  connection  with  other  cUnical  and  laboratory 
data,  is  of  considerable  value.  Positive  reactions  are 
rarely  obtained  in  the  achylias  of  primary  anemia,  simple 
achylia  gastrica,  and  simple  achlorhydrias,  when  such  are 
unassociated  with  gastric  motor  inefficiency, 

4.  Simple  gastric  and  duodenal  ulcers,  especially  when 
accompanied  by  pyloric  stenosis  or  gastric  atony,  may  give 
confusing  responses  to  the  Wolff-Junghans'  test. 

5.  The  presence  of  blood  in  gastric  extracts  may  be  a 
factor  in  the  production  of  certain  atypical  positive  tests. 

(B)  EXAMINATION  OF  THE  FECES  IN  GASTRIC  CANCER 

The  routine  examination  of  freshly  passed  feces  should 
never  be  neglected.  While  in  the  majority  of  instances  of 
the  disease,  analysis  of  the  stool  reveals  little  characteristic, 
not  infrequently  cases  occur  that  are  clinically  suspected  of 
being  gastric  cancer  where  stool  analysis  reveals  not  cancer 
of  the  stomach,  but  malignant  disease  of  the  large  bowel, 
rectum  or  anus,  anomalies  of  the  biliary  tract  or  pancreas, 
or  the  presence  of  intestinal  parasites. 

Macroscopic  clinical  reference  has  been  previously  made 
(vide  Chapter  III)  respecting  the  incidence  of  diarrhea  and 
constipation  in  gastric  cancer.  The  macroscopic  examina- 
tion of  the  stool  is  of  much  value.  Where  constipation 
exists,  its  degree  may  be  roughly  ascertained  by  marking 
of  the  stools  with  two  tablets  of  charcoal  or  5  grains  of  car- 
mine. With  the  patient  upon  diet  as  nearly  normal  as  pos- 
sible, the  time  of  administration  of  the  coloring  substance 
is  compared  with  that  when  the  stool  is  passed  stained 
black  (charcoal)  or  brick-red  (carmine).  We  have  found 
the  above  simple  method  of  considerable  clinical  value. 


EXAMINATION    OF    GASTRO-INTESTINAL    FUNCTION      257 

Roentgen  ray  examination  of  tiie  degree  of  stomach  or 
bowel  stasis  is  of  but  relative  service.  The  large  mass  of 
opaque  medium  is  not  physiologically  a  food.  It  is  not 
without  its  effect  upon  gastric  and  intestinal  secretions, 
peristalsis  or  digestive-tract  flora.  Its  weight  is  out  of  all 
proportion  to  its  bulk  as  a  food.  We  not  rarely  see  in- 
stances where  Roentgen  plates  show  bismuth  in  the 
intestinal  tract,  or  even  in  the  stomach  from  3  to  5  days 
following  its  administration,  and  yet  charcoal  or  carmine 
colored  stools  are  passed  within  12  to  24  hours.  It, 
therefore,  appears  that  Roentgen  estimation  of  gastro- 
intestinal motility  when  such  substances  as  bismuth  or 
barium  form  the  basis  of  the  test-meal  is  at  present  of 
dubious  service.  Its  value  can  only  be  placed  upon  a  firm, 
clinical  footing  when  actinologists  and  clinicians,  after 
years  of  co-operative  work,  have  followed  a  large  series  of 
similar  and  different  cases  through  medicinal  or  surgical 
treatment,  or  examined  such  at  autopsy.  Then  it  will  be 
proper  to  draw  conclusions  from  facts  and  not  have  such 
depend  upon  fancy  or  individual  enthusiasm. 

The  gross  appearance  of  sluggish  stools  in  instances  of 
gastric  cancer  may  differ  little  from  the  appearance  of 
constipation  stools  in  other  ailments.  If  little  food  is 
passing  into  or  out  of  the  stomach,  then  the  stools  may  be 
small,  hard  and  often  covered  with  mucus.  In  cases  where 
the  bile  tract  has  been  invaded  by  the  neoplasm  clay- 
colored  or  putty-like  movements  may  be  noted.  Where 
there  has  been  involvement  of  the  pancreas,  the  stool  may  be 
large  in  amount,  putty  or  gun-metal  colored,  pasty,  greasy, 
foamy  or  fatty,  contain  much  unaltered  food  (gobs  of  fat — 
butter-like  or  egg-yolk  appearing — or  chunks  of  poorly 
digested  meat  or  vegetable  fiber)  and  have  a  penetrating, 
pungent,    acrid,    musty    or    sour    odor.     Fistulous    com- 

17 


258         *   CANCER  OF  THE  STOMACH 

munication  between  stomach  and  bowel  may  cause  the 
stool  to  contain  macroscopic  blood,  necrotic  tissue,  pus, 
undigested  food  or  much  mucus.  Black  or  red  stools  occur 
when  sudden  extensive  bleeding  has  resulted  from  the 
local  growth  in  the  stomach,  or  from  necrosis  which  opens 
up  a  large  blood-vessel  as  a  consequence  of  secondary- 
invasion  of  other  viscera.    ' 

Diarrheic  stools  may  be  expected  at  any  time  during  the 
course  of  gastric  cancer.  Frequent!}^  they  are  caused  by 
faultj^  diet,  insufficiencj^  of  the  digestive  glands  (stomach, 
liver,  pancreas,  bowel),  asthenia,  nervous  disturbances, 
hemorrhage,  cohtis  associated  with  cardio-renal  compHca- 
tions,  abnormal  intestinal  microorganisms,  or  by  pressure 
or  actual  invasion  of  the  central  nervous  system  by  the 
neoplasm  or  by  medicines. 

The  stools  may  be  small,  frequent  and  watery,  large  and 
mush-like,  foamy,  sticky,  sUmy,  gelatinous  or  custard-like. 
The  odor  is  often  very  offensive.  The  color  varies  widely. 
Green,  tan,  cream,  j^ellow,  red  or  black  movements  are 
not  uncommon.  Occasionally  fleshy  clots  or  spongy  or 
friable  chunks  of  tissue  may  be  intermixed. 

CHEMICAL  EXAMINATION 

Reaction. — Stools  in  gastric  cancer  are  commonly  am- 
photeric or  alkaline  to  litmus  unless  there  is  a  marked 
involvement  of  the  pancreas  or  the  bile  ducts.  In  such 
event,  the  stools  have  acid  reaction  in  a  high  proportion 
of  cases. 

Hydrobilirubin  is  usually  present,  unless  the  free  flow  of 
bile  is  interfered  with  or  there  is  marked  cancerous  change 
in  the  liver. 

Bile  coloring  matter  is  readily  recognized  by  intimately 
mixing  10  grams    (or  10  cc.  in  case  the   stool    is  fluid) 


EXAMINATION    OF   GASTRO-INTESTINAL   FUNCTION     259 

of  stool  with  about  4  times  its  volume  of  saturated 
normal  salt  solution  of  bichloride  of  mercury  in  a  mortar. 
The  fluid  portion  is  poured  off  into  a  Petri  dish,  covered 
and  allowed  to  stand  for  from  2  to  24  hours.  If  hydro- 
bilirubin  is  present  a  salmon  to  deep  red  color  appears. 
Not  infrequently,  olive  green  color  changes  occur  due  to 
the  presence  of  biliverdin.  When  this  is  present,  chloro- 
phylaceous  moulds  or  certain  bacilli  associated  with  "  green 
diarrhea"  must  be  excluded  by  spectroscopic  examination 
of  alcoholic  extracts  of  the  feces.  Biliverdin  shows  no 
absorption  bands  spectroscopically.  All  stools  of  light 
yellow  to  putty  color  should  routinely  be  examined  for  bile 
pigments.  Very  often,  chalky  or  cream,  pale  yellow  or 
black  stools  render  it  difficult  to  observe  whether  or  not  bile 
elements  are  present.  Such  stools  are  common  when 
patients  are  on  milk  diet,  have  been  examined  by  the 
Roentgen  ray,  or  are  taking  certain  medicines  (bismuth, 
tannic  acid,  iron,  etc.). 

Blood. — After  severe  hemorrhage,  there  is  usually  no 
difficulty  in  recognizing  blood  macroscopically  in  the  stools. 
It  is  sometimes  necessary  to  be  sure  that  an  ulcer  sus- 
pected of  being  malignant  is  bleeding,  or  it  is  desirable  to 
ascertain  roughly  how  much  seepage  of  blood  is  occurring 
in  a  known  gastric  neoplasm.  For  this  purpose  chemical 
tests  for  altered  ('' occult")  blood  are  useful. 

It  should  be  strongly  emphasized  that  positive  chemical 
tests  for  blood  only  indicate  that  blood  pigment  is  in  the 
feces.  The  clinician  must,  therefore,  exclude  all  possible 
sources  of  error  before  he  can  state  definitely  that  a  chemical 
reaction  positive  for  blood  indicates  that  such  blood  comes 
from  the  suspected  gastric  focus.  It  should  be  strictly 
seen  that  no  likely  source  for  these  reactions  lies  in  a 
lesion   existing  in   the   mouth,    nasopharynx,   respiratory 


260  CANCER   OF   THE    STOMACH 

tract,  or  parts  of  the  digestive  canal  outside  of  the  stom- 
ach. Dependable  reagents  must  be  employed  in  making 
the  test.  Many  preparations  of  phenolphthalein,  guaiac,  or 
orthotoluidin  are  chemically  useless  for  the  reaction.  Ben- 
zidin  is  less  likely  to  be  unreliable,  provided  the  pinkish- 
gray  powder  be  used.  If  hydrogen  peroxide  or  turpentine 
is  employed,  it  is  very  essential  that  such  possess  de- 
pendable oxidizing  properties.  Thorough  dietetic  prepa- 
ration is  necessary  before  chemical  tests  for  blood  in  the 
stools  ^can  be  interpreted  clinically.  It  is  our  custom 
first  to  give  the  patient  2  ounces  of  castor  oil  and  thereby 
empty  the  gastro-intestinal  canal  of  material  likely  to  be 
a  source  of  error.  He  is  then  placed  upon  soft  lacto- 
vegetable  diet  (avoiding  excess  of  greens  and  fresh  garden 
truck)  for  3  days.  A  saline  cathartic  is  then  adminis- 
tered. For  the  following  24  hours  nothing  but  parboiled 
milk  is  permitted.  The  bowels  are  then  allowed  to  move 
naturally,  or  by  a  mild  saline  laxative.  The  second  stool 
passed  is  examined.  This  furnishes  the  specimen  to  be 
tested  for  altered  blood. 

The  method  of  procedure  has  been  described  above  (see 
Gastric  Analyses).  Care  should  be  taken  that  at  least 
5  grams  of  stool  are  employed  and  that  its  breaking  up 
with  acetic  acid  and  its  extraction  with  ether  are  thoroughly 
carried  out. 

Clinical  Interpretation  of  "OccuW  Blood  Tests. — If  the 
reaction  has  been  carefully  checked  as  outlined  above,  a 
positive  test  means  only  that  there  is  a  bleeding  point 
somewhere  between  the  lips  and  the  external  anal  ring. 
It  is  the  physician's  business  to  find  where  this  point  is 
located.  Given  a  history  of  a  malignant  gastric  ailment  or 
of  chronic  dyspepsia  of  the  ulcer  type,  it  is  most  likely  that 


EXAMIXATIOX    OF    GASTRO-IXTESTIXAL    FUXCTIOX      261 

persistent  seepage  or  intermittent  bleeding  come  from 
such  focus  of  disease. 

While  a  positive  chemical  reaction  for  blood  in  a  given 
specimen  of  feces  has  a  certain  value  diagnostically,  yet 
when  such  are  obtained  in  gastric  cancer,  other  more 
easily  and  more  dependable  signs  and  symptoms  of  the 
existence  of  the  disease  are  'not  lacking.  Of  the  stools  of 
gastric  cancer  patients  where  we  have  performed  benzidin 
tests,  the  reaction  was  positive  in  approximately  S9  per 
cent.  Of  this  group  of  cases,  abdominal  tumor  was  pal- 
pated in  nearly  75  per  cent.,  gastric  acidity  was  below 
15  in  83  per  cent.,  bacilh  of  the  Oppler-Boas  type  were 
present  in  stomach  extracts  in  nearly  94  per  cent.,  Roentgen 
findings  were  positive  or  suspicious  in  about  90  per  cent., 
and  the  clinical  history  was  that  of  malignancy  in  about  92 
per  cent,  of  instances. 

The  negative  test  for  ''occult '"  blood  in  the  feces  is  a  con- 
siderable aid  in  excluding  gastric  cancer  where,  with  a 
doubtful  clinical  history,  an  atypical  abdominal  tumor  is 
made  out. 

Ferment  Tests. — The  main  worth  of  such  lies  in  gaining 
knowledge  respecting  the  function  of  the  pancreas.  Tests 
for  amylase  (chastase)  and  trj^sin  appear  to  have  chnical 
value.  While  not  infrequently  low  figures  are  returned 
when  amylolytic  and  tryptic  digestion  are  estimated  in 
the  event  of  involvement  of  the  pancreas  by  a  growth, 
primarily  gastric,  we  have  found  that  in  cases  of  achyUa 
or  hypoacidity  of  extragastric  origin,  similar  results  may 
be  obtained. 

Wohlgemuth' s  Method  of  Determining  Diastase  in  the 
Stools. — Wohlgemuth  has  adopted  the  following  quantita- 
tive method  for  determining  the  diastase  in  the  stools: 
The  fresh  feces  are  well  mixed,  and  5  grams  are  thoroughly 


262  CANCEE  OF  THE  STOMACH 

ground  in  a  mortar  with  20  cc.  of  1  per  cent,  solution  of 
sodium  chloride,  added  a  small  quantity  at  a  time.  The 
emulsion  is  then  left  for  half  an  hour  at  the  room  tem- 
perature, stirring  it  frequentlj^  meanwhile.  It  is  now 
divided  into  two  equal  portions  of  10  cc.  each,  and  is 
transferred  to  graduated  centrifuge  tubes,  which  are 
centrifugahzed  until  all  the  solid  material  is  collected  at  the 
bottom  and  stands  at  the  same  height  in  both  tubes. 
The  quantities  of  sediment  and  supernatant  fluid  are 
noted.  Nine  test-tubes  are  now  taken.  Into  the  first 
three,  1.0  cc,  0.5  cc,  0.25  cc.  of  the  undiluted  extract; 
into  the  next  three,  1.0  cc,  0.5  cc,  0.25  cc.  of  an  eight- 
fold dilution  of  the  original  extract,  made  with  1  per 
cent,  sodium  chloride;  and  in  the  last  three,  1.0  cc, 
0.5  cc,  0.25  cc  of  a  sixty-four-fold  dilution  are  placed, 
so  that  each  tube  contains  half  the  fecal  extract  of  the 
preceding : 

1st  tube  1.0  4th  tube  0.125  7tli  tube  0.0156 

2nd  tube  0.5  5th  tube  0.0625  8th  tube  0.0078 

3rd  tube  0.25  6th  tube  0.0312  9th  tube  0.0039 

To  each  tube  5  cc  of  a  1  per  cent,  solution  of  starch  are 
then  added.  The  tubes  are  now  plugged  with  wool,  or 
closed  with  corks,  and  placed  in  the  incubator  at  38° 
C.  for  24  hours.  At  the  end  of  that  time  they  are  filled  to 
within  a  finger  breadth  of  the  brim  with  cold  distilled 
water,  one  drop  of  a  decinormal  iodine  solution  is  added  to 
each,  and  the  low^est  dilution  giving  a  blue  reaction  looked 
for.  It  is  then  assumed  that  the  tube  next  lowest  in  order 
contains  sufficient  diastase  to  convert  all  the  added  starch, 
and  from  this  the  quantity  of  1  per  cent,  starch  solution 
fermented  by  1  cc.  of  the  fecal  extract  can  be  calculated. 
Knowing  the  proportion  of  sohd  residue  to  hquid  extract 
in  the  5  grams  of  feces  the  quantity  of  ferment  corre- 


EXAMINATION    OF   GASTRO-INTESTINAL   FUNCTION     263 

spending  to  1  cc.  of  this  residue  can  be  determined  and 
from  this  the  diastatic  power  of  the  total  daily  mass  of 
feces  can  be  determined.  According  to  Wohlgemuth  and 
Wynhausen,  the  average  diastatic  value  of  the  feces  lies 
between  470  and  500.  To  obtain  satisfactory  results,  the 
feces  must  be  homogeneous  and  alkaline  in  reaction,  as 
diastase  does  not  act  in  an  acid  medium.  It  is  advisable 
to  place  the  patient  on  a  simple  mixed  diet,  calculated 
to  stimulate  the  functions  of  the  pancreas  to  normal 
activity,  for  a  couple  of  days  before  the  feces  are  collected 
for  examination  (Cammidge). 

Gross-Wynhausen^s  Method  of  Determining  Tryptic  Digestion 
in  the  Stools. — Wynhausen  has  suggested  the  following 
method  for  carrying  out  Gross'  test  quantitatively: 
Twelve  test-tubes  are  taken.  Into  the  first  two  are  placed 
0.25  cc.  and  0.1  cc.  of  the  undiluted  fecal  extract;  into  the 
next  five,  0.6  cc,  0.4  cc,  0.25  cc,  0.16  cc  and  0.1  cc  of  a 
10  times  dilution;  into  the  next  three,  0.05  cc,  0.25  cc,  and 
0.1  cc,  of  a  100  times  dilution;  and  into  the  last  two, 
0.5  cc.  and  0.25  cc  of  a  1000  times  dilution.  To  each  is 
now  added  5  cc.  and  0.1  per  cent,  casein  solution.  The 
tubes  are  closed  with  corks  or  wool  and  incubated  for  24 
hours.  At  the  end  of  this  time  they  are  tested  with  1 
per  cent,  acetic  acid.  The  digestion  of  1  cc  of  0.1  per 
cent,  casein  solution  by  1  cc.  of  the  filtrate  is  taken  as  the 
tryptic  unit.    Normally,  the  value  exceeds  200  (Cammidge) . 

MICROSCOPIC  EXAMINATION  OF  FECES  IN  GASTRIC  CANCER 

The  stools  should  be  examined  fresh  and  preferably 
warm.  It  is  our  practice  to  routinely  have  stools  col- 
lected in  warm  pots,  placed  at  once  in  an  incubator  built 
for  that  purpose  (Fig.  59)  and  examined  on  a  warm 
stage,  with  high  power  amplification.     Stools  should  be 


264 


CANCER    OF    THE    STOMACH 


examined  within  2  hours  after  their  being  passed  if  one 
desires  to  learn  facts  of  dependable  worth  regarding  the 
flora  of  the  intestinal  tract  or  to  make  representative 
cultures.  Whenever  possible  stools  should  travel  from 
patient  to  microscope  by  the  most  direct  route.     Stools 


K»5fWte;>: 


Fig.  59. — Electric  incubator  for  preserving   stools    warm  until  ready  for 
examination. — (Author. ) 

which  have  stood  about  for  hours,  grown  cold  or  allowed 
to  ''ferment"  return  wholly  unreliable  findings  upon 
microscopic  examination.  Food  rests  may  have  become 
digested  or  autolysized,  motile  bacteria  or  protozoa  have 
died  or  encysted,  or  abnormal  proliferation  of  such  organ- 
isms as  facultative  aerobes  taken  place. 

Method    of    Microscopic    Examination. — Much    can    be 
learned  from  examination  of  the  fresh  stool  unstained  but 


EXAMINATION    OF    GASTEO-INTESTINAL    FUNCTION      265 

diluted  about  3  times  with  warm  normal  salt  solution.  At 
least  one  preparation  should  be  viewed  in  this  manner, 
using  all  3  regular  objectives.  This  examination  permits 
the  recognition  of  motile  bacteria,  protozoa,  parasite 
eggs,  crystals  and  the  like,  relatively  unchanged.  Wet 
or  dry  stained  preparations  may  next  be  observed.  Wet 
preparations  are  conveniently  made  by  adding  a  drop  of 
Lugol's  solution  or  solution  of  osmic  acid  to  a  like  quan- 
tity of  fresh,  fluid  feces  upon  a  slide.  By  this  method 
food  digestion  (starches,  fats)  can  be  made  out.  Dry 
preparations  are  available  by  making  thin  smears  of  fluid 
feces  upon  cover  slips,  passing  through  a  Bunsen  flame 
rapidly,  and  staining  with  Wright's  solution,  Unna's 
polychrome  methylene  blue,  Loeffler's  blue,  hematoxylin 
and  eosin  or  Gram's  stain.  In  carcinoma  of  the  stomach, 
staining  by  polychrome  methylene  blue  or  Gram's  method 
is  a  satisfactory  routine  procedure.  Where  many  speci- 
mens are  to  be  examined  in  a  short  time,  the  agar  staining 
technique  which  I  suggested  several  years  ago  is  very 
useful  (see  under  Gastric  Analysis). 

Microscopic  Findings  in  the  Feces  in  Gastric  Cancer. — 
Where  the  malignant  process  is  early  or  developing  in  a 
pre-existing  ulcer,  nothing  characteristic  is  seen  in  the 
stools.  If  there  is  marked  gastric  stagnation  of  the  benign 
type,  an  abundant  growth  of  yeasts  and  sarcinse  may  be 
observed.  Where  gastric  malignancy  is  well  established, 
bacilli  of  the  Oppler-Boas  type  may  be  recognized  in  as 
high  as  60-85  per  cent,  of  cases  by  the  Gram  stain.  As- 
sociated with  these  long  acid-fast  bacilli,  there  are  com- 
monly large  colonies  of  streptococci  and  staphylococci. 

Protozoa  may  be  recognized  in  unstained  specimens  ex- 
amined on  a  warm  microscope  stage.  We  have  seen 
amoebae,   trichomonads,    cercomonads,    balantidium    coli, 


266  CANCER  OF  THE  STOMACH 

and  megastoma  entericum  in  the  feces  of  gastric  cancer 
patients.     Occasionally  tape-worms,  pin  worms  or  flukes 

are  seen. 

Undigested  food  is  common  in  the  stools  of  patients 
affected  with  cancer  of  the  stomach.  Large  pieces  of 
striated  muscle  fiber,  vegetable  reticula,  or  unaltered  fat 
may  be  abundant. 

Red  blood  corpuscles  and  leucocytes  (usually  polymorpho- 
nuclears or  of  the  large  mononuclear  type)  are  often  present 
in  sloughing  gastric  cancers,  or  where  fistulse  have  der 
veloped.  We  have  never  seen  mitotic  cells  in  the  feces  of 
such  cases. 

Crystals,  particularly  of  cholesterin,  ammonium  phos- 
phate, fatty  acids,  leucin  or  tyrosin  are  not  infrequently 
increased  in  the  stools  of  late  gastric  malignancy. 

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EXAMIXATIOX    OF    GASTRO-IXTESTIXAL    FrXCTION      267 

Sakfoed  and  Rosexbloom:  Arch.  Int.  'Med.,  1912,  ix,  p.  445. 

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Smithies:  Archiv  of  Int.  ]Med.,  1912,  x,  p.  357. 

SanTHiEs:  Jour.  Am.  Aled.  Assoc,  1912,  April  6,  p.  lOOS. 

Gees:  Quoted  by  Weinstein,  Jour.  Am.  Med.  Assn.,  1911,  Ivii,  p.  1420. 

Emersox:  "Clinical  Diagnosis,"  1906. 

Wolef  axd  Juxghaxs:  Berl.   klin.   Wchnchrft.,    1911,   May  29,   and 

1912,  March  18;  Medizin.  KHnik.  1912,  March  24,  also  Taschenbuch 

Magen  und  Darm  Krankheiten,  1912. 
Rolph:  Medical  Record,  New  York,  1913,  IMay  10,  p.  849. 
SiHTHiEs:  Am.  Jour.  Med.  Sc,  1914,  May,  p.  713. 
Smithies:  Jour.  Am.  Med.  Assn.,  1913,  Xov.  15,  p.  1793. 
Wohlgemuth:  Biochem.  Ztschrft.,  1909,  xxi. 
CAiiMiDGE:  "Feces  of  Children  and  Adults,"  London,  1913. 
Wtxh^iusex:  Berl.  klin.  Wchnschrft.,  1910,  No.  11, 


CHAPTER  VI 
ROENTGEN  EXAMINATION  IN  GASTRIC  CANCER 

During  the  past  5  years,  such  advances  have  been  made 
in  the  technique  of  examining  hollow  viscera  (which  have 
been  rendered  opaque  with  such  substances  as  bismuth 
or  barium),  through  the  medium  of  the  Roentgen  ray, 
as  to  permit  of  the  methods  being  of  certain  clinical  value. 

Class  of  Cases  in  which  Roentgen  Examination  is  of 
Value. — It  is  well  to  admit  that  much  of  the  positive  in- 
formation which  rc-ray  examinations  give  us  concerning  the 
function  or  abnormalities  of  the  stomach  can  be  as  well 
obtained  by  routine  clinical  examination.  This  especially 
applies  to  gross  lesions  of  the  stomach  or  bowel.  In  the 
large  majority  of  instances,  x-ray  findings  only  concern 
what  might  be  termed  accidents  in  the  progress  of  the 
disease  process.  By  this  we  mean  that  such  features  as 
stenosis  at  either  orifice,  or  on  the  course  of  the  gastric 
lumen,  alterations  in  shape  or  position  of  the  viscus  with 
relation  to  adjacent  organs,  or  deformities  in  outline  are 
determined  Roentgenographically.  Until  such  complica- 
tions occur,  it  is  not  unusual  for  Roentgen  findings  to  be 
entirely  negative.  The  diagnosis  must  be  made  clinically 
or  chemically.  This  applies  particularly  with  regard  to  the 
aj-ray  diagnosis  of  malignant  gastric  ulcer  and  latent  gas- 
tric cancer. 

Both  by  x-ray  plate  and  flouroscopic  screen  it  is  quite 
impossible  to  accurately  localize  or  even  diagnose  the 
majority  of  uncomplicated  peptic  ulcers.  Until  there  has 
been  such  accumulation  of  scar-tissue  as  to  make  a  lesion 

268 


EOEXTGEX    EXAMINATION    IX    GASTEIC    CANCEE         269 

1  to  3  cm.  in  diameter,  very  littie  of  definite  value  is  de- 
rived from  .r-ray  examination. 

In  tliese  instances,  the  so-called  .r-ray  diagnosis  of  early 
gastric  cancer  is  really  based  upon  other  clinical  and 
laboratory  data.  Xot  infreciuently  valuable  service  is 
rendered  by  the  Roentgen  ray  in  actually  demonstrating 
to  us  that,  in  a  patient  with  ulcer  symptoms,  the  disease  is 
located  in  the  stomach  and  not  in  the  duodenum.  This  is  a 
valuable  fact,  because  it  has  been  shown  by  the  work  of  the 
surgeon  and  the  cellular  pathologist  that  onh'  rarely  does 
malignancy  occur  upon  the  site  of  a  duodenal  ulcer.  In  our 
experience,  carcinoma  of  the  duodenum,  where  there  had 
been  previously  ulcer  history,  happened  but  7  times  in  an 
analysis  of  the  records  of  1.000  duodenal  ulcers. 

If  the  chronic,  recurrent,  calloused  ulcer  is  located  well 
within  the  stomach,  as  shown  by  the  .r-ray  examination, 
then,  from  a  knowledge  of  the  facts  that  Wilson  and 
MacCarty  have  found  cancerous  tissue  in  71  per  cent,  of 
such  ulcers  resected,  the  actinologist  can  C[uite  reasonably 
entertain  the  suspicion  that  such  ulcers  may  be  cancerous 
and  recommend  surgical  intervention.  ^Moreover,  if  the 
duodenal  ulcer,  which  is  quite  apt  itself  to  be  benign,  is 
proved  to  extensively  involve  the  pylorus  at  the  x-ray 
examination,  it  is  weU  to  suspect  that  such  ulcer  may  be  or 
is  potentially  carcinomatous. 

Similar  observations  may  also  be  made  regarding  ulcers 
or  scar-tissue  about  the  ulcer  causing  local  deformity  or 
local  irritation  of  groups  of  muscle  fibers  in  the  stomach  wall. 
Here  the  various  so-called  signs  are  quite  indefinite  and  un- 
certain, unless  the  facts  which  clinical  history  or  chemica] 
examination  of  gastric  function  return  are  considered. 

AYhen  a  large  accumulation  of  callus  has  formed,  or 
when  the  ulcer  breaks  throtigh  by  perforation,  or  where  the 


270  CANCER  OF  THE  STOMACH 

surface  mucous  membrane  has  been  lost  as  the  result  of 
necrosis,  thus  forming  a  crater-ulcer,  or  if,  in  the  attempt 
to  heal,  fibrous  tissue  has  caused  contraction  at  the  cardia 
or  in  the  stomach  lumen  (hour-glass  or  narrowing  at  the 
pylorus.  Figs.  60  and  61)  the  Roentgen  examination  of  the 
stomach  which  has  been  filled  with  opaque  medium  gives 
testimony  corroborative  of  the  clinical  opinion  that  such 
complication  has  occurred. 

We  have  already  shown  that  the  early  beginnings  of 
many  gastric  cancers  are  essentially  microscopic  alterations 
in  epithelium  lying  in  the  areolar  tissue  at  the  edges  or  bases 
of  gastric  ulcer.  When  this  pathologic  fact  is  borne  in 
mind,  it  is  to  be  readily  understood  how  the  a;-ray  examina- 
tion in  these  instances  can  only  give  information  with 
regard  to  the  presence  or  absence  of  calloused  ulcer.  It  is 
not  possible  to  state  whether  or  no  such  is  a  benign  ulcer 
or  a  malignant  ulcer.  Actinologists  have  learned  from  the 
clinical  pathologists,  however,  that  complicated  ulcers  of 
the  calloused  type  which  have  crater  diameters  or  scar- 
tissue  infiltration  broader  than  1  to  3  cm.  are  very  Ukely  to 
be  malignant.  This  applies  especially  to  ulcers  located 
at  or  neajr  the  cardia  or  the  pylorus. 

With  regard  to  ulcer  in  the  antrum,  pars  media,  or  the 
body  of  the  stomach,  it  is  frequently  impossible  to  make 
any  Roentgen  diagnosis  whatever  if  such  do  not  involve 
one  or  both  curvatures  and  produce  malformations  of  the 
stomach  outline. 

Inasmuch  as  we  have  shown  that  the  early  diagnosis  of 
gastric  cancer  is  essentially  that  of  the  diagnosis  of  chronic, 
calloused  ulcer,  it  will  be  seen  that  in  such  the  x-ray  evi- 
dence is  wholly  inefficient  with  regard  to  absolute  diagnosis, 
and  only  of  limited  value  with  respect  to  presumptive 
diagnosis.     It  is  to  be  regretted  that  in  these  cases  which 


ROENTGEN    EXAMINATION    IN    GASTRIC    CANCER        271 


Fig.  60. — -Benign  pyloric  obstruction. 
Case  No.  22,583— Male— Age  63. 

History  of  progressive  gastric  ulcer  with  recent  obstruction;  dilatation 
of  stomach  and  weight  loss. 

Abdominal  Examination. — Marked  tenderness  to  right  of  navel._ 

Test-meal. — Pronounced  12-hour  retention;  tan  color  extracts  with  yeasty 
odor.  Total  acidity,  68;  free  hydrochloric  acid,  63;  altered  blood  +  (Benzidin 
test). 

Microscopic  Examination. — Great  numbers  of  yeasts  and  sarcinse. 

Clinical  Diagnosis. — Pyloric  obstruction,  subacute  perforating  ulcer. 

X-Ray  Diagnosis. — Pyloric  obstruction. 

Plate  shows  "fish-hook"  stomach;  vigorous  peristalsis;  bulbous  antrum 
and  dilated  duodenum. 

Surgical  Diagnosis. — Pyloric  ulcer  with  obstruction. 


272 


CANCER   OF   THE    STOMACH 


Fig.  61. — Pyloric    obstruction;    duodenal   ulcer;    deficient  visualization  of 

pylorus  and  duodenum;  malignancy  questionable. 
Mr.  A.  Z.— Age  40. 

Family  History. — Negative. 

Previous  History. — Pneumonia  as  a  youth. 

Comes  on  account  of  chronic  indigestion  and  chronic  constipation. 

Duration  of  Disease. — Has  had  dyspepsia  all  of  his  life  in  infrequent  spells. 
These  attacks  always  came  on  gradually  and  were  characterized  by  epigas- 
tric distress  2  to  3  hours  after  meals  and  particularly  at  night.  The  distress 
was  usually  a  burning  sensation  and  occasionally  he  has  had  cramps.  The 
pain  usually  lasted  several  hours  and  was  frequently  transmitted  to  the  pre- 
cordia.  The  pain  was  aggravated  by  body  movement  and  relieved  by 
limiting  the  amount  of  his  diet,  gastric  lavage,  rest  or  by  pear  juice. 
Vomiting  would  come  on  regularly  at  night  if  the  stomach  was  not  lavaged 


ROENTGEN    EXAMINATION    IN    GASTRIC    CANCER         273 

make  up  the  bulk  of  instances  of  surgically  curable  cancer, 
Roentgen  examination  fails  as  a  clinical  method  of  precision. 

With  regard  to  early  so-called  ^'primary"  gastric  cancer 
— that  is  gastric  cancer  developing  in  stomachs  that  had 
previously  functionated  normally — the  x-ray  gives  prac- 
tically no  information.  At  the  time  when  anomalies  of 
the  stomach,  such  as  obstruction,  filling  defects,  malignant 
adhesions  or  perforation,  are  exhibited,  the  disease  process 
is  well  under  way. 

There  is  a  class  of  case,  however,  in  which  a:-ray  examina- 
tion aids  us  in  confirming  the  clinical  suspicion  that  a 
gastric  growth  exists.  Such  instances  are  where  the  neo- 
plasm is  located  on  the  lesser  curvature  near  the  cardia, 
at  the  fundus,  greater  curvature  or  posterior  wall.  This 
group  comprised  not  more  than  6  per  cent,  of  all  instances, 
in  a  study  of  187  consecutive  cases.  In  such  instances  it 
is  usually  impossible  to  feel  an  abdominal  tumor,  the 
history  is  obscure  and  such  thing  as  an  atypical  blood 
picture,  diarrhea,  or  regurgitant  vomiting,  may  make  it 
necessary  to  exclude  malignant  involvement  of  organs 
other  than  the  stomach.  In  no  instance  of  this  type  has 
the  x-ray  examination  returned  positive  information, 
however,    where    the    presumptive    diagnosis    of  gastric 

and  vomitus  would  consist  of  sour  food.  Never  suffered  any  nausea,  but 
belching  and  water-brash  were  fairly  constant. 

Appetite. — Food  desire  excellent. 

Bowels. — Markedly  constipated,  sometimes  do  not  move  for  a  week — 
bleeding.     Had  bloody  "flux"  lasting  3  days,  age  22.     Had  no  recurrence. 

Weight. — Six  months  ago,  weight  130;  present,  weight  100;  height,  6 
ft.  4  in. 

Temperament. — Markedly  neurotic — says,  "he  is  very  delicate  and  sensi- 
tive." 

Clinical  Diagnosis. — Peptic  ulcer;  enormously  dilated  stomach;  mentally 
deficient. 

X-ray  Diagnosis. — Perforating  duodenal  iilcer.  Plate  shows  dilated 
ptosed  stomach  of  the  fish-hook  type;  hyperperistalsis;  pylorus  shows 
deficient  filling  with  bismuth;  irregular  outline  with  a  residue  in  the  duo- 
denum. 

Surgical  finding. — Extensive  duodenal  ulcer  extending  to  and  involving 
the  pylorus;  adhesions  to  pancreas  but  no  perforation. 

18 


274  CANCER  OF  THE  STOMACH 

malignancy  had  not  been  strongly  considered  clinically. 
In  many  cases  the  stomach-tube  examination  alone 
has  been  quite  sufficient  to  estabhsh  positive  diagnosis 
in  a  few  minutes  and  at  little  expense  to  the  patient. 

In  the  great  number  of  instances  where  the  a;-ray  ex- 
amination showed  positive  diagnosis,  clinical  facts  had 
already  estabhshed  this.  For  example:  in  147  consecutive 
cases  of  proved  gastric  cancer,  there  was  palpable  epi- 
gastric ridge  or  tumor  present  in  72  per  cent.  In  this 
group,  gastric  retention  of  the  malignant  type  was  dem- 
onstrated in  74  per  cent. ;  occult  blood  existed  in  the  gastric 
extracts  in  92  per  cent,  and  in  the  stools  in  86  per  cent. 
The  microscopic  examination  of  gastric  extracts  showed 
bacilli  of  the  Oppler-Boas  type  in  93.8  per  cent.  In  this 
group  of  cases,  the  a;-ray  diagnosis  was  ''positive"  for  carci- 
noma, ''probably"  or  "possibly"  carcinoma  in  92  per  cent. 

The  information  of  the  greatest  value  which  the  Roentgen 
examinations  give  us  is  that  of  roughly  locating  the  posi- 
tion of  a  growth,  determining  the  extent  of  such,  visuahz- 
ing  the  deformity  existing  in  the  stomach,  and  sometimes 
indicating  the  invasion  of  adjacent  viscera.  Roentgen 
examinations  have  a  not-to-be  neglected  psychic  value. 
They  make  it  much  easier  to  convince  the  patient  or 
medical  attendant  that  carcinoma  exists,  or  does  not  exist, 
than  if  such  an  examination  had  not  been  made.  They 
also  permit  of  interesting  visualization  of  diseased  organs. 
In  this  way,  valuable  service  may  be  rendered  by  enabling 
one  to  regard  the  different  phases  of  the  disease  in  a  patient 
under  various  types  of  surgical  or  non-surgical  treatment. 

METHODS  OF  EXAMINATION  BY  MEANS  OF  THE  ROENTGEN  RAY 

There  are  two  useful  methods  in  vogue :  the  examination 
by  making  plates  or  films  and  the  examination  by  means  of 


ROENTGEN   EXAMINATION   IN    GASTRIC    CANCER        275 

the  fluoroscopic  screen.  Our  experience,  from  the  study  of 
the  records  of  more  than  2,000  gastro-intestinal  a;-ray 
examinations,  would  indicate  that  neither  method  is  all- 
sufficient,  but  that  the  greatest  amount  of  information  is  to 
be  obtained  by  a  combination  of  both  procedures.  It  is 
such  method  that  we  deem  best  to  describe. 

EXAMINATION  BY  FLUOROSCOPIC  SCREEN 

This  examination  has  for  its  object  two  main  ends.  The 
first  is  to  demonstrate  the  ability  of  the  stomach  to  empty 
itself  of  ingested  material.  The  second  is  the  examination 
of  the  stomach  filled  with  a  medium  opaque  to  the  Roentgen 
rays  for  the  purpose  of  noting  abnormalities,  with  and 
without  the  aid  of  abdominal  palpation  or  change  in  the 
patient's  position. 

To  test  the  emptying  power  of  the  stomach  it  is  our  practice 
to  first  wash  out  the  stomach  so  as  to  free  it  from  an  ac- 
cumulation of  food  that  may  have  resulted  from  improper 
diet.  The  next  procedure  is  to  empty,  as  far  as  possible, 
the  gastro-intestinal  tract  by  means  of  a  cathartic.  For  this 
purpose,  we  use  2  ounces  of  castor  oil  in  a  half  glass  of 
beer  or  malt  extract,  or  mixed  with  a  small  amount  of  iced 
water,  lemon  or  orange  juice.  The  patient  is  then  kept 
on  a  liquid  diet  for  from  8  to  12  hours.  He  is  then  fed  a 
so-called  "motor-meal."  We  have  found  it  useful  to  feed 
this  in  the  form  of  bismuth  subcarbonate  or  barium  sulphate 
in  Cream  of  Wheat.  The  proportions  are  2-A  ounces  of 
either  of  these  drugs  to  8  ounces  (cooked  weight)  of  Cream 
of  Wheat.  This  mush  may  be  flavored  with  fruit  juices. 
A  little  cream  is  permissible.  The  patient  eats  the  mush 
slowly,  and  is  not  usually  told  its  ingredients. 

Six  hours  after  this  motor-meal,  the  stomach  is  examined 
by  means  of  the  fluoroscopic  screen  and  x-ray  tube.     The 


276  CANCER  OF  THE  STOMACH 

patient  is  stripped  of  all  excepting  a  light  surgical  gown. 
We  prefer  to  examine  our  patients  standing,  but  there  is  no 
objection  to  conducting  the  examination  with  the  patient 
seated  (say  upon  a  high  bicycle  seat)  or  even  lying  upon  a 
proper  table.  The  form  of  apparatus  used  is  of  Httle 
consequence  so  long  as  one  has  available  a  first-rate  fluoro- 
scope  screen  (the  best  are  imported  from  Germany  or 
France)  and  a  number  of  high-grade  water-cooled  x-ray 
tubes.  Many  good  tubes  are  made.  Those  which  have  a 
cooling  arrangement  in  the  form  of  a  continuous  current 
of  water  (after  the  suggestion  of  Albers  Schoenberg)  are 
very  satisfactory.  The  new  tube  devised  by  Coolidge  is 
most  excellent. 

Negative  Findings. — If  there  is  no  mechanical  interference 
to  food  entering  the  stomach  (stricture  at  the  cardia),  to 
its  passage  through  the  stomach  (tumor  mass,  mahgnant 
hour-glass,  perforation,  adhesions)  or  to  its  exit  from  the 
stomach  (malignant  stenosis  at  the  pylorus),  at  the  end 
of  6  hours  the  ''motor-meal"  of  bismuth  or  barium  mush 
will  have  left  the  stomach.  The  mass  of  it  will  be  located 
in  the  lower  ileum  or  some  part  of  the  large  bowel. 

Positive  Findings. — If  malignant  obstruction  has  oc- 
curred, in  the  above-named  fashion,  one  may  see  varying 
amounts  of  bismuth  in  the  esophagus,  in  a  loculus  of  the 
stomach  or  lying  at  the  most  dependent  part  of  the  viscus. 
In  but  few  extensive  gastric  cancers  does  the  stomach  empty 
itself  completely  of  the  motor-meal.  Even  if  the  orifices 
are  wide  open,  it  is  not  uncommon  to  find  ''rests"  of  the 
opaque-meal  lying  between  projections  or  in  the  irregular- 
ities formed  by  the  neoplasm.  The  absence  of  all  the 
motor-meal  from  the  stomach  is  not  a  conclusive  proof 
that  the  orifices  are  not  involved.  It  is  not  uncommon  to 
discover  at  laparotomy,  in  such  instances,  a  hard  gristle- 


ROENTGEN   EXAMINATION   IN    GASTRIC    CANCER        277 

like  neoplasm  extensively  involving  the  pylorus  and 
antrum.  This  may  so  stiffen  the  gastric  wall  that  the 
lumen  remains  patent  and  allows  the  opaque  meal  to  pass 
rapidly  into  the  small  gut  after  the  fashion  of  liquid 
flowing  through  a  funnel. 

In  our  experience  6-hour  opaque  ''rests"  of  a  motor- 
meal  are  seen  in  approximately  2  out  of  3  cases  of  gastric 
cancer  where  there  is  moderately  extensive  involvement. 

Fluoroscopic  Examination  of  Abnormalities  in  Gastric 
Outline. — For  this  purpose  it  is  necessary  to  almost  fill  the 
stomach  with  a  puree-like  mixture.  In  this  manner,  one 
can  then  observe  shape,  size,  position,  contour,  emptying 
power  and  tender  points  of  the  stomach.  One  can  also 
determine  the  relation  of  the  stomach  to  adjacent  viscera, 
and  rapidly  note  the  effect  of  peristalsis  or  the  influence 
upon  the  above  factors  brought  about  by  change  of  position 
or  by  abdominal  palpation. 

The  opaque  liquid  which  we  have  found  useful  consists  of 
6  to  8  ounces  of  bismuth  subcarbonate  or  barium  sulphate 
in  1,000  cc.  of  buttermilk,  ''fermilac,"  or  thin  starch-paste. 
These  mixtures  may  be  flavored  with  chocolate,  vanilla  or 
fruit  juices.     Usually  little  flavoring  is  necessary. 

After  examining  the  stomach  for  a  6-hour  ''rest"  de- 
scribed under  estimation  of  motor  function,  the  patient  is 
next  permitted  to  drink  500  to  1500  cc.  of  the  bismuth 
subcarbonate  or  the  barium  sulphate  puree.  While  this  is 
being  taken,  the  esophagus  is  scrutinized  with  the  patient 
in  both  the  anterior,  posterior  and  lateral  positions.  This 
maneuver  permits  of  one  gauging  the  size  and  patency  of 
the  esophagus  and  also  makes  it  possible  to  note  the  freedom 
with  which  the  opaque  mixture  passes  the  cardia.  Note 
should  be  carefully  made  regarding  these  points  and  if  there 
is    abnormality   observed,   repeated    examination    should 


278  CANCEK  OF  THE  STOMACH 

demonstrate  its  permanency  or  its  transientness.  If 
such  anomaly  be  permanent,  a  record  should  be  obtained  of 
it  upon  plates. 

In  cases  where  there  is  no  abnormality  noted  in  the 
esophagus  or  at  the  cardia,  the  stomach  should  be  observed 
as  the  opaque  meal  enters.  Depending  upon  the  thick- 
ness of  the  abdominal  parietes,  the  excellence  of  the 
tube  and  screen,  and  the  success  with  which  the  opaque 
meal  has  been  made,  one  usually  observes  in  gastric  cancer, 
first,  that  there  is  some  fault  in  the  gastric  outline.  This 
fault  consists  most  generally  of  a  diminution  in  the  size 
of  the  gastric  lumen.  This  is  due  to  the  fact  that  the 
majority  of  malignant  growths  extend  into  the  stomach 
cavity  and  hence,  at  these  points,  there  is  a  defect  of  normal 
gastric  filling  due  to  the  intrusion  into  the  lumen  of  solid 
tissue.  This  may  be  of  greater  or  less  extent.  Generally, 
the  most  marked  "filling-defects"  are  seen  toward  the 
pylorus,  that  is,  in  the  region  where  gastric  cancer  is  most 
common.  They  may  occur,  however,  at  any  part  of  the 
stomach.  They  result  in  atypical  irregularities  of  the 
lumen.  In  some  instances  they  totally  occlude  the  gastric 
cavity.  On  account  of  the  fact  that  gastric  cancers  are 
generally  of  the  medullary  type,  one  not  infrequently  sees 
that  the  outline  of  the  gastric  lumen  is  irregular,  or  has  a 
worm-eaten  or  old  cheese  appearance.  This  condition 
exists  because  the  nodular  projections  of  the  growth  permit 
of  varjdng  amounts  of  bismuth  lodging  between  them. 
Hence,  the  Roentgen  ray  penetrates  greater  quantities 
of  bismuth  at  some  parts  than  at  others. 

Whatever  may  be  the  situation  of  the  gastric  neoplasm, 
if  it  has  advanced  far  enough  to  be  recognized  by  the 
a;-ray,  there  is  always  encroachment  upon  the  lumen  of  the 
organ  at  some  point.     In   cases  of  scirrhus   growth  in- 


ROENTGEN   EXAMINATION   IN    GASTRIC    CANCER        279 

vading  largely  the  submucosa,  there  is  a  smaller  lumen 
than  ordinarily  shown.  The  lumen  may  be  quite  uniform 
in  such  instances,  but  due  to  the  thickness  of  the  gastric 
wall,  the  resultant  cavity  is  contracted  (so-called  ''leather- 
bottle  stomach"). 

When  the  growth  is  at  the  cardia,  not  infrequently  such 
is  difficult  to  recognize  due  to  the  left  lobe  of  the  liver,  the 
lower  ribs,  the  breast  or  the  sternum  lying  in  front  of  it. 
Careful  examination,  however,  usually  discloses  some  out- 
line defect  or  some  atypical  way  in  which  the  opaque  me- 
dium enters  the  stomach.  In  normal  cases,  a  fluid  passing 
the  cardia  seems  to  closely  hug  the  lesser  curvature  {magen- 
weg).  Where  there  is  some  fault  at  the  cardia,  one  not 
infrequently  sees  that  the  bismuth  is  delayed  in  the 
esophagus.  When  it  does  enter  the  stomach,  it  may  pass 
in  in  several  streams,  may  not  hug  the  lesser  curvature,  or 
it  falls  through  in  large  drops  or  gobs.  Above  neoplasms 
at  the  cardia  there  may  be  extensive  dilatation  or  the 
esophagus  may  even  be  infiltrated  by  the  tumor. 

When  the  growth  is  high  in  the  lesser  curvature,  the  lumen 
is  usually  encroached  upon  in  a  characteristic  way.  If, 
however,  the  growth  is  not  very  soft  or  papillomatous  the 
outline  of  the  lesser  curvature  may  be  fairly  regular.  The 
resultant  appearance  then  may  be  difficult  to  differ- 
entiate from  a  normal  lesser  curvature  pushed  to  the  left 
by  an  extragastric  tumor  (liver,  gall-bladder,  pancreas,  retro- 
peritoneal sarcoma).  In  this  event  an  examination  of  the 
patient  in  different  positions  will  often  serve  to  delimit  the 
esophagus.     It  may  even  be  infiltrated  by  the  tumor. 

When  the  growth  is  situated  in  the  body  or  the  pars  media 
of  the  stomach,  fluoroscopic  examination  usually  makes 
evident  local  narrowing  of  the  gastric  lumen.  The  extent 
of  this  depends  upon  the  size  of  the  neoplasm.     Often,  hour- 


280  CANCER  OF  THE  STOMACH 

glass  loculation  is  seen.  Occasionally,  several  gastric 
chambers  are  apparent,  partly  or  wholly  filled  with  the 
shadow-casting  substance.  Xot  infrequently,  in  extensive 
tumor  involvement,  all  that  remains  of  the  stomach's 
lumen  is  a  narrow,  usually  tortuous,  canal,  through  which 
the  bismuth  or  barium  mixture  passes  in  an  attenuated 
stream  and  is  visible  with  difficulty.  If  such  canal  has 
between  it  and  the  screen  a  great  mass  of  cancer  tissue, 
opaque  media  in  it  may  not  be  evident.  The  test-meal 
may  then  be  seen  in  an  upper  (usually  larger)  loculus  and 
appear  again  in  a  cavity  toward  the  antrum  or  pylorus. 

Growths  involving  the  antral  or  the  pyloric  region  generally 
manifest  their  presence  by  such  intrusion  upon  the  gastric 
cavity  as  to  produce  partial  or  nearly  complete  obstruction 
to  the  onward  passage  of  the  bismuth  or  barium  meal. 
In  these  instances  gastric  emptying  power  may  be  greatly 
deficient,  delayed  or  lost.  Consequently,  even  bimanual 
massage  of  the  epigastrium  cannot  force  the  opaque 
mixtures  forward  in  such  amount  as  to  permit  the  visualiza- 
tion of  the  pyloric  channel  or  the  duodenum.  If  the 
growth  in  these  locations  is  firm  or  large,  there  is,  com- 
monl}',  compensatory  dilatation  of  the  stomach.  Such 
neoplasms  intrude  so  greatly  into  the  narrow  distal  end  of 
the  viscus  as  to  render  much  of  its  channel  invisible  or 
only  recognizable  as  a  wavy  canal  wandering  between 
indefinitely  delimited  cancer  masses.  Not  rarely,  the  entire 
pyloric  third  of  the  stomach  appears  chopped  or  torn  off 
and  only  a  few  rests  of  bismuth  or  barium,  in  its  general 
direction  or  lodged  in  the  viscera  beyond,  indicate  that 
some  canalization  of  the  mass  exists. 

There  is,  as  we  have  mentioned  above,  a  certain  type  of 
tumor  (usually  of  the  class  styled  '^scirrhus")  which  may 
extensively  infiltrate  large  sections  of  the  pyloric  end  or 


ROENTGEN   EXAMINATION   IN    GASTRIC    CANCER        281 

even  the  entire  wall  of  stomach,  without  producing  ob- 
struction. In  such  cases,  the  pylorus  may  gape  and  gastric 
contents  rapidly  escape  into  the  small  intestine.  Usually, 
however,  the  general  thickness  of  the  stomach  wall  results 
in  narrowing  of  the  gastric  lumen,  locally,  toward  the 
pylorus  or,  generally,  throughout  the  stomach.  The  lumen 
thus  appears  small,  often  tapering  in  a  funnel-like  manner 
toward  the  duodenum.  Its  boundaries  may  be  slightly 
fringed,  wavy  or  irregular.  In  any  event,  a  relatively 
small  gastric  shadow  is  visible  upon  the  fluorescent  screen. 
The  shadow  may  be  pyriform,  gourd-shape  or  bottle-like. 

Cancers  directly  upon  the  posterior  or  anterior  wall,  unless 
large  enough  to  produce  deformity  of  the  stomach,  may 
reveal  little  evidence  of  their  presence  unless  various  por- 
tions of  the  stomach  are  successively  silhouetted  either  by 
abdominal  palpation,  or  by  observing  the  filled  viscus  at 
different  angles  (anterior-posteriorly,  standing  and  re- 
clining; laterally,  from  both  sides,  standing  and  lying,  etc.). 
In  the  case  of  growths  on  the  posterior  wall,  great  difficulty 
may  be  experienced  in  differentiating  such  from  tumors  of  the 
liver,  pancreas,  retroperitoneal  tissues  or  left  kidney. 

In  general  gastric  carcinosis,  occlusion  of  the  normal 
lumen  may  be  so  extensive  that  very  little  may  be  recog- 
nized. Instead,  ^'flecks"  or  larger  ''rests,"  the  shadow- 
casting  media  may  be  intermingled  with  gas  bubbles  and 
solid  tissue,  the  whole  giving  indefinite  shadows  (mottling, 
dappling,  sponge-like,  or  thick  soap  suds  appearance)  in  the 
region  where  we  normally  locate  the  stomach,  or  where 
abdominal  palpation  permits  the  recognition  of  a  tumor. 

In  gastric  cancer,  where  early  or  late  ulceration  has 
occurred,  one  can  frequently  delimit  definite  craters,  with 
ragged  edges,  and  these  often  retain  rests  of  bismuth  or 
barium.     If  such  have  become  adherent  to  adjacent  viscera 


282  CANCER  OF  THE  STOMACH 

or  perforated  into  these,  then  the  adhesion  or  the  false 
channel  can  sometimes  be  established. 

Peristalsis  is  generally  not  evidenced  by  vigorous  gastric 
contractions  in  cancer  of  the  stomach,  unless  the  process  is 
implanted  on  an  ulcer  and  not  far  advanced,  or  unless  a 
small  (often  ring-like)  growth  causes  hour-glass  contraction 
or  pyloric  stenosis.  The  invasion  of  the  stomach  wall  by 
malignant  disease  appears  to  early  bring  about  varying 
grades  of  gastric  atony  or  palsy.  In  non-obstructive 
growths,  where  the  stomach's  emptying  time  is  better  than 
normal,  it  would  seem  that  weakness  of  the  walls  of  the 
viscus  rather  than  strength  or  frequency  of  peristaltic 
waves  permit  the  heavy,  opaque  mixtures  to,  roughly 
speaking,  ''fall  through"  into  the  duodenum.  This  is 
particularly  marked  where  there  are  few  nodulations  to  the 
growth  or  where  the  neoplasm  is  located  proximal  to  the 
antrum. 

Palpation  is  one  of  the  most  valuable  maneuvers  during 
fluoroscopy.  By  its  use,  one  is  able  to  establish  the  mova- 
bility  of  the  stomach,  to  delimit  the  lumen  completely,  to 
fill  or  empty  ulcer  craters,  to  test  the  patency  of  the  pylorus 
or  cardia,  to  outline  the  boundaries  of  the  duodenum,  to 
prove  the  relationship  of  the  stomach  to  other  viscera,  to 
locate  a  palpable  abdominal  mass  with  respect  to  its  being 
gastric  or  extragastric,  to  test  its  mobility,  to  estimate  the 
relative  involvement  of  the  stomach  by  such  mass,  or  to 
uncover  gastric  neoplasms  (as  on  posterior  wall)  which 
direct  view,  without  palpation,  does  not  reveal.  Tender 
areas  can  be  roughly  located  with  respect  to  their  associa- 
tion with  parts  of  the  stomach.  Thus,  one  may  sometimes 
gauge  the  presence  or  absence  of  perforation  and  peritoneal 
invasion.  In  instances,  where  free  fluid  exists  in  the  ab- 
dominal  cavity,   palpation  enables   one   to  recognize  its 


EOENTGEN   EXAMINATION   IN    GASTRIC    CANCER        283 

presence  and  extent  and  by  observing  the  limits  of  such 
with  the  patient  in  different  postures  to  demonstrate  its 
situation  with  respect  to  the  abdominal  viscera.  Of 
course,  common  clinical  tests  frequently  return  informa- 
tion equalty  valuable.  There  seems  to  be  a  peculiar 
satisfaction,  however,  in  the  visualization  of  these  phe- 
nomena, The  psychic  effect  of  these  maneuvers  upon  the 
patient  or  his  friends  appears  to  be  highly  valued  in  some 
quarters. 

THE  EXAMINATION  BY  MEANS  OF  ROE NTGENO  GRAPHIC 
PLATES  OR  FILMS 

The  perfection  of  the  fiuoroscope  has  rendered  this 
method  largely  obsolete,  tedious,  of  little  added  clinical 
worth  and  unnecessarily  expensive.  There  are  few  cases 
of  gastric  cancer  where  any  Roentgenographic  evidence  is 
at  all  possible,  that  cannot  be  quite  as  successfully  recog- 
nized by  aid  of  the  fluoroscopic  screen  as  by  a  series  of 
plates  or  films.  The  fine  distinctions  which  certain  ob- 
servers demonstrate  upon  18  to  40  successive  plates,  while 
they  may  have  artistic  worth  have  little  practical,  clinical 
value.  The  multiplication  or  diminution  of  the  number 
of  shadows  in  an  area  in  which  already  one  knows  that  a 
tumor  exists,  while  entertaining  to  certain  minds  is  clinically 
as  meaningless  and  non-essential  as  are  the  multitudinous 
incongruities  of  a  cubistic  canvas. 

The  physical  effort  demanded  of  a  desperately  ill  and 
generally  weak  patient  in  the  making  of  a  large  series  of 
plates  is  often  a  serious  consideration.  The  expense  of 
the  maneuver  is  out  of  all  reasonable  proportion  to  the 
worth  of  the  information  returned.  As  we  have  men- 
tioned above,  in  a  series  of  147  gastric  cancers  where  the 
x-rsLj  examination  gave  information  of  possible  or  positive 


284  CANCER  OF  THE  STOMACH 

diagnostic  worth  in  92  per  cent,  of  instances,  by  such 
inexpensive  and  simple  procedure  as  microscopic  examina- 
tion of  stained  smears  of  gastric  extracts  or  vomitus,  bacilli 
of  the  Oppler-Boas  type  were  demonstrated  in  93.8  per 
cent.  But  rarely  are  bacilli  of  this  type  observed  in  non- 
malignant  conditions. 

Certain  value  is  found  in  the  making  of  a  few  radio- 
grams in  gastric  cancer.  Such  enable  one  to  keep  a 
record  of  the  progress  of  a  non-operated  case,  to  recognize 
recurrences  after  excision  of  a  tumor,  to  corroborate  fluoro- 
scopic observations  and  as  an  aid  in  advancing  knowledge. 
It  is  thought  by  some  that  prints  from  plate  series  are 
not  without  advertising  value,  even  if  of  little  scientific 
worth,  provided  they  be  sent  abroad  appropriately  be- 
decked. The  unique  scientific  spirit  which  prompts  this 
course  is  productive  of  much  unwarranted  cancerphobia. 
However  successful  a  trade  venture  it  may  be,  it  cannot 
be  too  strongly  condemned  as  a  professional  act. 

Mode  of  Procedure. — Ordinarily,  after  the  fluoroscopic 
examination  of  gastric  function,  it  is  possible  to  proceed 
with  the  plate  making.  If  records  of  an  opaque-meal 
''rests"  remaining  after  6  hours  is  desired,  plates  may  be 
made  before  the  complete  fluoroscopic  examination-  is 
made. 

After  the  fluoroscopic  examination,  the  stomach  should 
be  filled  again  with  bismuth  or  barium  puree.  This  is  to  be 
especially  urged  if  the  gastric  emptying  time  has  been 
rapid.  Radiograms  of  the  partially  filled  stomach  do  not 
enable  one  to  deUmit  its  outline  accurately. 

When  the  stomach  has  been  filled,  plates  are  made  in 
the  usual  manner.     In  uncommon  cases,  it  is  advisable  to 
expose  the  plates  with  the  patient  successively  standing,  . 
recumbent  or  lying  on  one  or  the  other  side.     In  this 


EOEXTG 


:tEX  examination  in  gastric  cancee      285 


p,,,  ,;o_  C'l^e  No  19,539).— MaUgnant  hour-glass  stomach  with  ante- 
cedent ht.ton'o^Scexi  partial  obstmctTon  at  cardia,  with  bismuth  m  dJ^ated 
esophagus.  Tuberculosis  of  stomach  ^patient  also  had  pulmonary  tubei- 
culosisj. 


286 


CANCER   OF   THE    STOMACH 


Fig.  63. — Irregular  primary  cancer  history:  involvement  of  cardia    and 

pylorus. 
Mr.  W.  K.— Age  62. 

Personal  History. — Negative. 

Duration  of  Present  Ailment. — About  1  year,  trouble  has  been  continuous, 
with  recent  aggravation. 

Comes  on  account  of  dyspepsia,  abdominal  pain,  weight  and  strength  loss 
and  anemia. 

Discomfort  is  located  in  the  epigastrium,  is  described  as  a  "dull  ache" 
and  "shuts  off  wind."  It  is  more  or  less  constant,  but  worse  immediately 
following  food  ingestion.  It  is  transmitted  to  rib  edges.  Distress  relieved 
by  limiting  diet,  bj^  vomiting  and  rest. 

Patient  vomits  two  or  three  times  a  week  (usually  in  the  afternoon). 
Vomitus  consists  of  sour  liquid  and  food.  The  emesis  is  brought  on  by  pain. 
Water-brash  and  pyrosis  are  annoying. 


EOENTGEN  EXAMINATION  IN  GASTRIC  CANCER   287 

way,  one  is  least  likely  to  fail  in  the  recognition  of  a  gastric 
deformity.  Its  extent  can  be  better  calculated  by  such 
procedure. 

If  a  series  of  plates  is  desired,  such  may  be  made  rapidly, 
as,  for  example,  15  to  25  within  20  minutes  followed  by  plates 
made  at  from  1-  to  6-hour  intervals  until  the  gastro-intestinal 
tract  has  freed  itself  of  bismuth  or  barium  mixtures.  There 
are  numerous  ingenious  mechanical  devices  for  making  such 
a  plate  series.  In  admiration  of  the  perfection  of  these 
contrivances  one  may  readily  lose  sight  of  the  fact  that  the 
information  they  return  to  us  has  little  actual,  chnical 
worth. 

The  Information  Derived  from  Roentgenograms  in 
Gastric  Cancer. — In  early  cancer  there  are  no  positive  x-tslj 
signs  beyond  those  of  compHcated  ulcer  or  obstruction, 
whatever  may  be  the  location  of  the  growth.  Where  well- 
estabhshed  carcinoma  is  located  at  the  cardia  permanent 
record  may  be  obtained  of  dilatation,  iuA'olvement  or  dis- 
placement of  the  esophagus,  alterations  in  outUne,  size, 
position  and  patency  of  the  cardia  and,  rarely,  evidences 
of  perforation  to  adjacent  viscera. 


Appetite  is  variable. 

Bowels  have  been  constipated  for  7  montlis. 

Weight. — ^Loss  of  23  pounds  in  past  year. 

Abdominal  Examination. — Tender  ridge  in  upper  right  epigastrium, 
moving  to  region  of  navel  on  inflation  of  stomach. 

Tesf-meaZ.— Stomach  tube  meets  no  resistance  at  cardia.  Xo  12-hour 
retention.  75  cc.  of  cream  yellow,  rancid  contents  removed.  Total  acidity, 
8;  free  hydrochloric  acid,  0;  altered  blood+;  lactic  acid,?;  Wolff-Junghans' 
test,  0;  formol  index,  24. 

Microscopic  Examination. — Few  food  bits,  Oppler-Boas  bacilH  ?,  sarcinse 
(large  form);  numerous  deeply  staining,  lance-shaped  rods;  leptothrix-H; 
many  polynuclear  leucocytes. 

Stool. — Altered  blood-}-  (benzidin  test). 

Clinical  Diagnosis. — Aehlorhydria;  ulcus  carcinomatosum. 

X-ray  Diagnosis. — Filling  defect  at  cardia  and  pylorus,  probable  carci- 
noma, scoliosis.  Plate  shows  a  blunted  "steer-horn"  stomach,  with 
moderate  dilatation,  peristalsis  is  almost  absent.  On  high  lesser  curvature 
appears  a  filling-defect  of  the  crater-ulcer  type;  the  chopped-off  pylorus 
appears  to  be  due  to  a  tumor.     The  duodenum  is  dilated. 

Surgical  Diagnosis. — Inoperable  carcinoma. 


288 


CANCER    OF   THE    STOMACH 


ti020 


tt 


pa' 


iI^^bR 


Fig.  64. — (Case  No.  19,020). — Inoperable  gastric  cancer,  involving  cardia 

and  pars  media. 


ROENTGEN    EXAMINATION    IN    GASTRIC    CANCER        289 


Fig.  65. — Pyloric  obstruction;  gastric  carcinosis. 
Case  No.  23,650— Mr.  J.  H.— Age  78. 

Abdominal  Examination. — Movable  mass  in  mid-epigastrium;  stomach 
moderately  dilated. 

Test-meal. — Twelve-hour  retention;  gastric  extracts,  tan  color;  rancid 
odor.  Total  acidity,  10;  free  hydrochloric  acid,  0;  altered  blood,  ?  (benzidin 
test) ;  lactic  acid  + ;  Wolff- Junghans'  test,  0. 

Microscopic  Examination. — Numerous  food  rests;  great  numbers  of 
bacilli  of  Oppler-Boas  type;  few  budding  yeasts. 

Clinical  Diagnosis. — -Pyloric  obstruction  due  to  inoperable  gastric  cancer. 

X-ray  Diagnosis. — Carcinoma  of  stomach;  marked  hypertrophic  arthritis 
of  spine. 

Plate  shows  pyloric  half  of  stomach  and  lesser  curvature  invaded  by  nodu- 
lar growth;  lumen  nearly  obliterated  in  antrum  and  pylorus;  no  visualiza- 
tion of  duodenum  or  distal  viscera. 

Surgical  Diagnosis. — Irremovable  gastric  tumor. 

19 


290 


CANCER    OF    THE    STOMACH 


Fi.j.  06. —  ^'ase   Xo.   23,14,;. — Perforating  ulcer    malignant    ?)  on  lesser 
curvature;  gaping  pjdorus. 


ROENTGEN   EXAMINATION   IN    GASTRIC    CANCER        291 


Fig.  67. — Chronic    perforating    gastric    ulcer;    malignancy    questionable; 

hour-glass  contraction. 
Mr.  H.  C.  C— Age  36. 

Previous  History. — Negative. 

Comes  on  Account  of  chronic  intermittent  indigestion  and  chronic 
constipation. 

Duration  of  Disease. — Attacks  of  dyspepsia  for  the  past  18  years;  has 
three  or  four  attacks  a  year.  Is  usually  worse  in  spring  and  fall.  Trouble  has 
been  constant  during  the  last  3  months.  The  attacks  are  characterized  by 
pain  in  the  upper  left  epigastrium,  come  on  usually  3  to  4  hours  after  eating 
and  after  he  gets  to  bed  at  night.  Pain  is  a  soreness,  a  hard  ache  or  a  colic. 
At  present  he  is  never  free  from  distress,  but  rehef  is  obtained  by  food  inges- 
tion, vomiting,  rest  or  alkaUes.  Pain  is  usually  transmitted  to  the  left 
costal  margin  and  to  the  tip  of  the  left  scapula.     Vomiting  is  of  almost  daily 


292  CANCER    OF   THE    STOMACH 

If  the  fundus  or  cardiac  portion  of  the  lesser  curvature 
is  affected,  irregularities  in  outline  with  lagging  of  the 
opaque-meal,  narrowing  of  the  lumen  or  signs  of  adhesion  or 
perforation  may  be  determined. 

When  the  neoplasm  has  invaded  the  body  of  the  stomach 
marked  irregularities  in  the  outline  of  the  gastric  channel  are 
not  rarely  seen.  There  may  be  such  constriction  of  the 
lumen  as  to  produce  hour-glass  form.  Peristaltic  activity 
is  usually  diminished.  It  may  be  almost  absent.  Dilata- 
tion of  the  stomach  or  of  one  or  both  loculi  (in  the  event  of 
hour-glass  type),  with  misplacement  due  to  perigastric 
adhesions  (often  malignant)  or  perforation  are  not  uncom- 
monly visualized.  In  some  instances  definite  crater  forma- 
tion upon  the  top  of  nodule  projecting  into  the  stomach 
lumen  may  be  made  out.  When  the  growth  is  limited  in 
extent  or  confined  to  the  anterior  or  posterior  walls,  few 
radiographic  signs,  apart  from  alterations  in  peristalsis  or 
rate  of  onward  progression  of  the  opaque-meal,  may  be 
evident.  Observation  made  with  the  patient  in  different 
positions  sometimes  helps  to  elucidate  a  seemingly  negative 

occurrence  but  usually  follows  almost  immediately  after  food  ingestion.  It 
is  brought  on  by  abdominal  pain  and  the  sensation  of  food  sticking  "at  the 
entrance  to  the  stomach."  Eructations,  belching,  water-brash  and  pyrosis 
are  very  marked. 

Appetite. — Capricious. 

Weight  Loss. — None. 

Hemorrhage. — Helena  IJ^  years  ago  followed  by  severe  hematemesis. 
Nine  days  ago  had  severe  hemorrhage  from  stomach  and  bowels  and  fainted. 

Bowels. — Constipation  for  the  past  18  years. 

Ahdominal  Examination. — Tenderness  and  dulness  very  marked  in  the 
mid-epigastrium . 

Test-meal. — Moderate  12-hour  retention.  Gastric  contents,  tan  brown 
in  color  and  of  sour  odor.  Total  acid,  70;  free  hydrochloric  acid,  70; 
altered  blood -H. 

Microscopic  Examination. — ^ Yeasts;  sarcinse. 

Clinical  Diagnosis. — Subacute  perforating  lesser  curvature  ulcer  with 
obstruction. 

X-ray  Diagnosis. — Perforating  ulcer  of  the  stomach,  lesser  curvature;  hour- 
glass stomach.  X-ray  plate  shows  bi-loculation  of  the  stomach  due  to  con- 
striction in  the  pars  media.  The  channel  is  very  narrow  at  this  point  and 
just  above  it  on  the  lesser  curvature  is  an  ulcer  crater  containing  a  bismuth 
rest.  The  incomplete  filling  of  the  lesser  curvature  of  the  upper  loculus 
makes  it  impossible  to  say  whether  this  process  is  malignant  or  benign. 


ROENTGEN    EXAMINATION    IN    GASTRIC    CANCER         293 


Fig.  Gb.— (Case    No.    20,Gl(Jj. — liour-gla.sb    feLoiiiuch;  _  saddle    ulcer    pars 
media;  gaping  pylorus;  spasm  at  cardia. 


294 


CANCER   OF   THE    STOMACH 


Fig.  69. — Achlorhydria;  indefinite  clinical  picture.     Filling  defect  of  pars 

media. 


EOENTGEN   EXAMINATION    IN    GASTRIC    CANCER        295 


DESCRIPTION  OF  FIG.  69 

Mr.  P.  P. — Age  62 — Farmer. 

Past  History. — Typhoid  fever,  19  years  previously. 

Comes  on  account  of  anorexia,  weight  and  strength  loss,  anemia,  mild 
dj'spepsia.  Patient  felt  perfectly  well  up  to  4  weeks  ago.  Gradually  lost 
appetite  and  experienced  vague,  bloated  sensations  in  the  upper  abdomen. 
These  have  been  continuous,  but  are  most  marked  soon  after  food  ingestion. 
Recently  has  vomited  in  the  late  afternoon,  and  obtained  relief  of  abdominal 
discomfort.  Never  vomited  blood  or  food  retained  more  than  a  haK  day 
Suffers  nausea  soon  after  eating.  Occasionally  experiences  regurgitation  of 
food.     Has  been  growing  paler  during  past  fortnight. 

Appetite. — Very  poor.  Bowels  moderately  constipated.  Never  noted 
melena. 

Weight. — ^Loss  of  33  pounds  in  past  2  months. 

Abdominal  Examination. — Dubaess  and  area  of  deep  tenderness  above 
the  navel.     Negative  otherwise.  ^ 

Test-meal. — No  12-hour  retention;  stomach  slightly  dilated.  Gastric 
extract  is  cream  colored  and  food  poorly  chymified.  Total  acidity,  10;  free 
hydrochloric  acid,  0;  altered  blood  +  (benzidin  test);  lactic  acid,  0;  Wolff- 
Junghans'  test  +. 

Microscopic  Examination. — Shows  a  few  budding  yeast  cells. 

Stool. — Altered  blood. 

Clinical  Diagnosis. — Achlorhydria;  carcinoma. 

X-ray  Diagnosis. — Apparent  filling  defect  in  pylorus,  antrum  and  lesser 
curvature.     Pylorus  gapes.     Suspicious  of  malignancy. 

Plate  reveals  a  modified  "fish-hook"  stomach;  peristalsis  fairly  active, 
duodenum  well  visualized,  apparent  canalization  of  a  growth  toward  pyloric 
fifth  of  the  stomach. 

Surgical  Diagnosis. — Cancer  at  the  pyloric  end  of  the  stomach. 


296 


CANCER    OF   THE    STOMACH 


Fig.  70. — Carcinoma  involving  greater  curvature  and  posterior  wall. 


ROENTGEN   EXAMINATION    IN    GASTRIC    CANCER        297 


DESCRIPTION  OF  FIG.  70 

Mrs.  C.  C.  W.— Age  53. 

Previous  History. — Hysterectomy  13  years  ago. 

Comes  on  account  of  chronic  dyspepsia,  weiglit  and  strengtli  loss,  anemia. 

Duration  of  Disease. — Spells  of  dyspepsia  on  and  oif  for  the  past  20  years 
at  infrequent  intervals.  Attacks  have  been  characterized  by  pain  in  the 
upper  left  abdominal  quadrant.  Would  last  for  days;  were  coUcky  and 
gassy  in  character;  were  most  marked  when  the  patient  had  an  attack  of 
diarrhoea.  Pains  did  not  seem  to  be  aggravated  by  dietetic  variations. 
Were  usually  reUeved  bj*  rest  or  by  vomiting,  belching,  pyrosis  or  regurgi- 
tation. 

Appetite. — Food  desire  very  good. 

Boioels. — Four  to  seven  movements  a  day  for  the  past  10  months.  Light 
in  color. 

Weight  Loss. — Thirty-five  pounds  in  1  year. 

Abdominal  E.xamination. — Dulness  in  Traube's  space.  In  upper  mid- 
epigastrium  a  large  thick  tumor  is  palpated.  Stomach  holds  23  ounces, 
greater  curvature  is  3  finger  breadths  below  the  navel  line. 

Test-meal. — 100  cc.  of  tan  and  brown  poorly  chyniified  material  removed 
after  57  minutes.  Marked  bleeding  on  manipulation  of  tube.  ^Moderate 
amount  of  previous  evening  meal  recovered.  Very  free  hemorrhage  on 
lavage.  Total  acidity,  22;  free  hydrochloric  acid.  0;  altered  blood  +  (benzi- 
din  test;)  Wolff-Junghans'  test  -|-;  lactic  acid.  0. 

Microscopic  Examination. — Oppler-Boas  bacilli.  Alany  short  bacilli 
in  pairs.     Numerous  red  blood  cells  and  food  remains. 

Clinical  Diagno.ns. — Extensive  inoperable  gastric  cancer  with  involvement 
of  cardia. 

X-ray  Diagnosis. — Probable  carcinoma  of  the  stomach. 

Plate  shows  steer-horn  stomach  with  moderate  ptosis  and  extensive  filling 
defects  in  the  region  of  the  body,  antrum  and  pylorus. 

Surgical  Diagnosis. — Inoperable  carcinoma. 


298 


CANCER   OF   THE    STOMACH 


Fig.  71. — (Case  No.  19,359). — Extensive  cancer  of  stomach  with  filling 
defects  at  pars  media  and  pyloric  end.  Pylorus  is  displaced  to  the  left.  It 
is  patent.     Duodenum  visualized  and  dilated. 


EOEXTGEX    EXAMINATION    IX    GASTRIC    CAXCER         299 


Fig.  72. — (Case  Xo.   1,906). — Scirrhus  cancer  of  stomach.;  funnel-shaped 
stomach;  pj'lorus  displaced  to  left  and  patent;  duodenum  visualized. 


300 


CANCER   OF   THE    STOMACH 


Fig.  73. — History  suggesting  chronic  perforating  peptic  ulcer;  syphilis  (?); 
lesser  curvature  ulcer  (malignant  ?);  demonstrated. 


ROENTGEN   EXAMINATION    IN    GASTRIC    CANCER        301 


DESCRIPTION  OF  FIG.  73 

Mr.  W.  P. — Age  58 — Farmer. 

Personal  and  Family  Histories. — Syphilis.? 

Duration  of  Present  Ailment. — Infrequent  attacks  of  dyspepsia  for  3  years. 
Trouble  has  been  constant  for  past  month. 

Complains  of  abdominal  pain,  indigestion  and  recent  weight  loss.  Pain 
is  marked  in  the  mid-epigastrium,  is  of  severe  aching  and  "doubling  up" 
type  and  usually  transmitted  to  the  right  costal  margin.  Pain  comes  on 
usually  4  to  5  hours  after  meals  and  lasts  until  something  is  eaten.  Is  less 
comfortable  on  light  diet.  Relief  of  distress  is  also  obtained  by  peppermint 
water  and  rest. 

Vomiting — ^usually  brought  on  as  result  of  sudden  movement,  occurs 
irregularly.  Pyrosis  is  annoying  at  irregular  intervals,  but  usually  relief 
is  obtained  by  drinking  peppermint  water. 

Appetite. — Fair. 

Bowels. — Constipation  alternating  with  diarrhoea. 

Abdominal  Examination. — To  right  and  above  navel  is  an  indefinite, 
fixed,  tender  I'idge.     Stomach  splashy. 

Test-meal. — No  12-hour  retention.  Gastric  extract  is  of  light  green  color. 
Test  food  is  well  chymified.  175  cc.  recovered.  Total  acidity,  30;  free 
hydrochloric  acid,  30;  altered  blood,  0;  lactic  acid,  0;  Wolff -Junghans'  test,  ?; 
formol  index,  19.2. 

Microscopic  Examination. — Food  remains,  yeasts  and  diplococci. 

Clinical  Diagnosis. — Subacute  perforating  ulcer  lesser  curvature.  Malig- 
nant change.?     Syphilis.? 

X-ray  Diagnosis. — Calloused  ulcer  of  the  stomach. 

Plate  shows  ulcer  crater  on  lesser  curvature  with  deep  incisura  on  greater 
curvature  at  about  the  same  level.  It  is  impossible  to  say  whether  or  not 
the  tilcer  is  malignant. 

Stomach  empties  freely,  pyloric  end  is  in  state  of  moderate  contraction; 
duodenum  is  poorly  visualized. 

Surgical  Diagnosis. — Ulcer  on  lesser  curvature  with  chronic  perforation. 


302 


CANCER   OF   THE    STOMACH 


Fi(..  74. 
Case  No.  20,799— Male— Age  62. 

History  that  of  chronic  perforating  gastric  ulcer  with  suspicion  of  recent 
malignant  change. 

X-ray  Diagnosis. — Perforating  ulcer  on  lesser  curvature. 

Operative  Findings. — Large  ulcus  carcinomatosum  on  lesser  curvature. 


ROENTGEN   EXAMINATION   IN    GASTRIC    CANCER        303 

case  as  shown  by  routine  technique  where  in  such  case 
test-meal  findings  and  clinical  examinations  strongly  point 
toward  gastric  cancer. 

Carcinoma  at  the  pyloric  end  of  the  stomach  is  commonly 
associated  with  some  grade  of  gastric  retention  and  quite 
often  with  compensatory  dilatation  of  the  viscus.  This  is 
not  always  demonstrated  because  occasionally  the  stomach 
is  involved  locally  in  a  tough,  gristle-like  growth  that 
stiffens  the  wall,  thereby  maintaining  a  widely  patent 
lumen,  with  not  infrequently  a  gaping  pylorus.  Little 
detail  of  the  cancer,  Roentgenographically,  may  be  possible 
in  such  instances  on  account  of  the  rapid  emptying  of  the 
stomach.  There  may  be  few  or  no  opaque-meal  ''rests." 
Ordinarily,  invasion  of  the  antrum  or  pylorus  results  in 
great  change  in  the  caliber  of  the  lumen.  This  may  be 
narrowed,  generally  or  locally,  with  resultant  tortuous, 
irregular,  bulbed,  lobulated,  funnel-shaped,  or  almost 
invisible  gastric  channel.  Perforation  or  ulceration  may 
produce  accessory  chambers  filled  with  bismuth  or  barium, 
or  reveal  evidences  of  involvement  of  fiver,  pancreas, 
adjacent  bowel  or  the  peritoneal  cavity. 

There  are  instances  where  ring  cancers  at  or  near  the 
pylorus  produce  striking  local  constriction  of  the  lumen 
with  marked  obstruction.  If  such  cancer  occurs  directly 
at  the  pylorus,  the  blunt,  abruptly  cut-off  termination  of  the 
stomach,  with  dilatation  of  the  viscus,  generally,  or  the 
antrum,  locally,  associated  with  failure  of  visualization  of 
the  duodenum,  is  a  fairly  characteristic  picture.  In  this 
type  of  neoplasm,  peristalsis  may  be  quite  active. 

With  the  object  of  demonstrating  the  relative  worth  of 
Roentgenographic  evidence  in  gastric  cancer,  we  have  ar- 
ranged a  series  of  Roentgenograms  in  association  with  other 
clinical  and  surgical  findings.     It  will  be  observed  that  in 


304 


CANCER    OF   THE    STOMACH 


Fig.  75. — Pyloric  obstruction;  malignant  ulcer  (?) 


ROENTGEN    EXAMINATION   IN    GASTRIC   CANCER        305 


DESCRIPTION  OF  FIG.  75 

Mr.  G.  H.  S. — Age  37 — American. 

Comes  on  account  of  chronic  constipation  and  chronic  intermittent 
dyspepsia. 

Previous  History, — Typhoid  fever  when  a  youth. 
'  Duration  of  Present  Complaint. — For  past  12  years  has  had  attacks  of 
painful  dyspepsia,  lasting  for  several  weeks  and  coming  on  usually  in  the 
fall.  These  attacks  have  been  characterized  by  soreness  or  gnawing  pains 
in  the  pit  of  the  stomach,  which  distress  usually  came  on  1  to  2  hours  after 
meals  and  at  night.  The  distress  would  last  until  food  was  ingested  or 
vomiting  occurred .  Alkalies  and  limited  diet  have  been  frequently  required . 
Pain  was  generally  referred  to  the  back,  between  the  shoulders.  Vomiting 
occurred  irregularly  and  was  most  common  in  the  evening.  Belching  and 
pyrosis  have  been  annoying.  Dyspepsia  constant  and  more  marked  past 
6  weeks. 

Appetite. — Good  desire. 

Bowels. — Very  constipated  for  10  years.     During  the  past  3  months  this 
has  been  aggravated. 

Bleeding. — -Two  weeks  ago  severe  hematemesis. 

Weight. — Lost  10  pounds  during  past  2  months. 

Abdominal  Examination. — Very  tender  in  right  upper  quadrant.  Stomach 
splashy. 

Test-meal. — Marked  12-hour  retention;  300  cc.  recovered;  extracts  are 
tan-brown  and  with  yeasty  odor.  Total  acidity,  48;  free  hydrochloric  acid, 
46;  altered  blood,  0  (benzidin  test). 

Microscopic  Exajnination. — -Many  food  rests.  Yeasts  and  sarcinse  in 
excess. 

Clinical  Diagnosis. — Pyloric  obstruction;  duodenal  ulcer. 

X-ray  Diagnosis. — Pyloric  obstruction;  probable  duodenal  ulcer. 

Plate  shows  large  "steer-horn"  type  stomach  with  hyperperistalsis  and 
irregular  filling  out  of  pylorus;  duodenum  is  but  faintly  visualized. 

Surgical  Findings. — Chronic  "saddle-ulcer"  on  lesser  curvature  at 
pylorus. 

Without  microscopic  examination  it  was  impossible  to  tell  whether  ulcer 
was  malignant  or  benign. 


20 


306 


CANCER    OF   THE    STOMACH 


Fig.  76. — Achlorhydria :  Nervous    patient;    irregular    ulcer    liistorj^    with 
recent  exacerbation;  pyloric  cancer. 


ROENTGEN    EXAMINATION    IN    GASTRIC    CANCER        307 


DESCRIPTION  OF  FIG.  76 

Mr.  P.  F.'jC. — Age  45— Manual  laborer. 

Previous  History. — Typhoid  fever  as  a  youth. 

Comes  on  account  of  abdominal  pain,  dyspepsia,  nervousness,  recent 
weight  and  strength  loss. 

Duration  of  Disease. — Intermittent  dyspepsia  for  past  5  years.  The 
present  attack  has  persisted  for  3  weeks. 

The  disturbance  is  characterized  by  distress  across  the  mid-epigastrium 
and  by  belching  and  water-brash.  These  symptoms  are  moderately  con- 
stant, but  more  pronounced  when  the  stomach  is  empty,  or  immediately 
after  eating.  Distress  is  often  transmitted  to  the  precordia.  It  is  relieved, 
partially,  by  food  intake,  catharsis  or  rest.  Belching  and  water-brash  come 
on  usually  soon  after  eating.  Alkalies  relieve  the  distress  occasioned 
thereby. 

Mentality. — Below  par,  patient  highly  psychic  and  excitable. 

Appetite. — Poor. 

Weight. — Lost  11  pounds  past  3  weeks  and  29  in  past  year. 

Test-meal. — No  12-hour  food  retention;  gastric  contents  cream  tan  in 
color.  Total  acidity,  10;  free  hydrochloric  acid,  0;  altered  blood,  0  (benzidin 
test);  lactic  acid,  0;  glycyltryptophan  test-f-. 

Microscopic  Examination. — Numerous  small  lymphocytes  and  cocci  in 
short  stains  and  small  groups. 

Stool. — Altered  blood+. 

Clinical  Diagnosis. — Gastric  achlorhydria  (carcinoma  ?);  psychasthenia. 

X-ray  Diagnosis. — Carcinoma  of  pyloric  end  of  stomach. 

Plate  demonstrates  "steer-horn"  type  of  stomach,  with  extensive  filling 
defect  of  the  antrum  and  pylorus.  Tumor  is  irregularly  canalized.  Pylorus 
is  patent.  Bulbus  duodeni  is  deformed.  Motor  meal  rests  in  ascending, 
transverse  and  descending  portion  of  the  colon. 

Surgical  Diagnosis. — Cancer  of  pyloric  end  of  stomach. 


308 


CANCER   OF   THE    STOMACH 


Fig.  77. — Pyloric  ulcer,  motor  meal  residue — perforating  ulcer. 


ROENTGEN   EXAMINATION   IN    GASTRIC    CANCER        309 


DESCRIPTION  OF  FIG.  77 

Mr.  P.  W.— Age  48— Irish. 

Family  History. — Negative. 

Comes  on  account  of  chronic  intermittent  dyspepsia.  Duration  of 
disease  20  years  in  spells  or  attacks.  These  attacks  have  been  characterized 
by  marked  epigastric  pain  coming  on  1  to  3^  hour  after  meals  or  at  night. 
Pain  is  usually  very  sharp  but  sometimes  a  gnawing  and  burning  sensation. 
Usually  lasts  several  hours  and  is  transmitted  to  the  back  between  the  shoul- 
der blades.  Pain  is  relieved  by  food  intake,  vomiting  and  alkalies.  Has 
several  times  required  morphine.  During  the  last  3  weeks  the  distress  has 
been  constant  and  vomiting  has  been  an  annoying  symptom.  Vomiting 
usually  occurs  about  13^  hours  after  meals  and  seems  to  be  brought  on  by 
abdominal  pain.  The  vomitus  is  sour  water  and  sometimes  food.  There 
has  been  no  delayed  vomiting.  Nausea  has  been  marked  especially  in  the 
evening.  Eructations,  water-brash  and  pyrosis  are  particularly  distressing 
at  night.     They  are  relieved  by  alkalies. 

Appetite. — Poor. 

Bowels. — Constipated;  never  any  bleeding. 

Weight  Loss. — Eighteen  pounds  in  6  months. 

Clinical  Diagnosis. — Partial  pyloric  obstruction,  due  to  peptic  ulcer 
(malignancy  questionable),  moderate  dilatation  of  the  stomach. 

X-ray  Findings. — -Moderate  6-hour  retention  (Rieder  meal);  peristalsis 
active,  incomplete  visualization  of  pylorus  and  duodenum ;  tenderness  over 
region  of  pylorus,  possible  ulcer  of  the  stomach  or  duodenum. 

Surgical  Findings.- — Chronic  perforating  ulcer  of  the  duodenum  to  liver 
and  chronic  appendicitis. 


310 


CANCER    OF   THE    STOMACH 


R 

JSOfM 


Fig.  78. — (Case  No.  20,594).- — -Clironic,  recurrent  ulcer    (malignant  ?)  at 
pylorus  with  partial  obstruction. 


ROENTGEN    EXAMINATION    IN    GASTRIC    CANCER         311 


fl 


YiG  79— (Case  No.  22,157).— Pyloric  obstruction.  Plate  shows  dilated 
stomach  with  extensive  neoplastic  involvement  of  antrum  and  pylorus; 
pylorus  partly  patent;  fair  gastric  peristalsis. 


312 


CANCER   OF   THE    STOMACH 


Fig.  80. 
Case  No.  20,905— Male— Age  41. 

Iiivolvement  of  pyloric  third  of  stomach  by  cancer  following  history  clinic- 
ally that  of  ulcer.     Rests  of  motor-meal  seen  below  stomach  in  colon. 


ROENTGEN   EXAMINATION   IN    GASTRIC    CANCER         313 


19218 


Fig.  81.- — (Case  No.  19,219). — Cancer  of  pars  pylorica  following  history 
clinically  that  of  ulcer;  partial  pyloric  obstruction  to  physiologic  motor- 
meal.  Dilated  small  bowel  partly  filled  with  bismuth,  suggesting  an 
obstruction  distally. 


314 


CANCER   OF   THE    STOMACH 


Fig.  82. — Pyloric  obstruction,  malignant. 
Case  No.  23,652— Male— Age  48. 

Previous  History. — Clinically  that  of  chronic,  recurrent  peptic  ulcer. 
Two  previous  operations  demonstrated  such. 

Abdominal  Examination.— -Inde&nite  ridge  in  mid-epigastrium. 

Test-meal. — Slight  12-hour  food  retention.  Gastric  extracts  cream-tan 
color.  Poorly  chymified.  Total  acidity,  10;  free  hydrochloric  acid,  0; 
altered  blood,  ?  (benzidin  test);  lactic  acid-1-;  Wolff- Junghans'-j-  test. 

Microscopic  Examination. — Numerous  bacilli  of  Oppler-Boas  type;  few 
budding  yeasts. 

Clinical  Diagnosis.- — Carcinoma  following  ulcer;  questionably  operable. 

X-ray  Diagnosis. — Carcinoma  of  stomach. 

Plate  shows  tumor  mass  involving  pyloric  third,  with  irregular  canaliza- 
tion of  mass,  but  gaping  pylorus,  permitting  rapid  exit  of  bismuth  into 
duodenum  and  small  bowel  (which  are  visualized).  Lesser  curvature  is  also 
infiltrated; 

Surgical  Diagnosis. — Gastric  cancer. 


ROENTGEN   EXAMINATION    IN    GASTRIC    CANCER         315 


Fig.  83.— (Case    No.    20,730j.— Recumng   gastric   cancer,    with    partially 
patent  gastro-enterostomy  stoma. 


316 


CANCER    OF    THE    STOMACH 


Fig.  84. — Pyloric    obstruction;    previous    irregular    peptic    ulcer    history; 
irremovable  gastric  tumor;  syphilis. 


EOEXTGEX    EXAMINATION    IN    GASTRIC    CANCER         317 


DESCRIPTION  OF  FIG.  84 

Mr.  M.  S. — Age  40 — German — Merchant. 

Previous  History. — Genital  sore  in  youth.  Abdominal  section  (else^vhere) 
1  year  ago;  gastric  ulcer  ?. 

Comes  on  account  of  chronic  indigestion,  weight  and  strength  loss,  anemia. 

Duration  of  Disease. — For  past  12  years  has  had  attacks  of  indigestion. 
These  were  characterized  by  epigastric  distress  several  hours  after  meals, 
belching,  pyrosis  and  loss  of  appetite.  Distress  and  associated  symptoms 
were  relieved  by  food,  alkalies  or  diet.  Eighteen  months  ago  the  symptoms 
became  so  annoying  that  patient  was  unable  to  work.  A  year  ago  had 
laparotomy  and  thinks  ulcer  and  adhesions  were  found.  Did  fairly  well  up 
to  3  months  ago.  Since  then  has  had  constant  epigastric  pain,  worse 
immediately  after  meals  and  at  night,  and  only  partially  reUeved  by  rest 
and  limited  diet.     Eructations  and  pyrosis  have  been  annoying. 

Appetite. — Poor. 

Bowels. — Unexplainable  diarrhea  for  past  4  days.     Never  bled. 

Weight.- — Lost  11  pounds  last  2  months. 

Abdominal  Examination. — Healed  laparotomy  scar.  In  mid-epigastrium 
to  right  of  scar  and  adherent  to  it  is  an  oval,  fixed,  tender  nodule. 

Test-meal. — Moderate  12-hour  retention.  Gastric  extract  cream  color, 
with  sour  odor.  Total  acidity,  14;  free  hydrochloric  acid,  0;  altered  blood+ 
(benzidin  test;;  Wolff-Junghans'  test+;  formol  index,  20;  lactic  acid,  0. 

Microscopic  Examination. — -Numerous  bacilli  of  the  Oppler-Boas  type, 
budding  yeasts  and  small  form  sarcinse,  few  streptococci. 

Clinical  Diagnosis. — Pyloric  obstruction;  partial  hour-glass;  achlorhydria; 
gastric  cancer  on  old  ulcer.     Syphilis  ?     Inoperable. 

X-ray  Diagnosis. — Probable  carcinoma  or  syphilis  of  the  stomach. 

Plate  shows  small  modified  "steer-horn"  type  of  stomach.  The  lumen  of 
the  pyloric  half  is  encroached  upon  by  a  mass  so  extensively  as  to  almost 
obliterate  it;  nodular  infiltration  is  denoted  by  the  irregular  outline  of  the 
curvatures,  particularly  the  greater;  obstruction  is  shown  by  failure  to  visual- 
ize the  duodenum  or  parts  of  the  bowel  distal  to  it. 

Surgical  Diagnosis. — Irremovable  gastric  tumor. 


318  CANCER  OF  THE  STOMACH 

the  majority  of  cases,  clinical  diagnosis  was  quite  possible 
without  the  added  a;-ray  examination;  that  in  clinically 
doubtful  cases,  the  Roentgenographic  diagnosis  was  sim- 
ilarly dubious.  The  plates  form,  however,  an  interesting 
accessory  record  to  the  histories,  and  aid  in  selection  of 
cases  likely  to  be  benefited  by  surgical  procedures,  by  indi- 
cating, roughly,  the  location  of  the  growths  and  the  extent 
that  they  invade  the  gastric  wall  or  involve  other  viscera. 


CHAPTER  VII 
THE  BLOOD  IN  GASTRIC  CANCER 

The  terms  ''malignancy"  and  ''cachexia"  have  become 
so  closely  associated  as  result  of  years  of  clinical  investi- 
gation, that  the  mention  of  one  suggests  the  other.  Of  the 
numerous  evidences  of  cachexia  with  neoplastic  foundation, 
anemia  is  one  most  commonly  recognized  by  both  layman 
and  physician.  Certain  gross  manifestations  of  the  cancer- 
ous anemia  are  often  appreciated  upon  even  casual  ex- 
amination. 

The  skin  is  usually  dry,  loose,  scaly,  muddy,  grayish- 
white  or  of  fawn  or  lemon-yellow  tint.  Were  the  early 
decrease  in  the  amount  of  subcutaneous  fat  not  of  fre- 
quent occurrence,  the  skin-tint  might  readily  be  mistaken 
for  that  observed  in  such  constitutional  fault  associated 
with  that  clinical  picture  which  we  call  pernicious  anemia. 
The  sclera  are  commonly  pearly  white,  but  may  be  dis- 
colored or  faintly  yellow.  Mucous  surfaces  exhibit  varying 
degrees  of  paUor.  They  are  generally  dry  and  often  shiny. 
Those  of  the  Ups  and  tongue  maybe  fissured  or  herpetic. 
The  tongue  is  frequently  pale,  dry,  roughened  and  coated. 
Capillary  edema  accumulates  about  the  malleoli.  Some- 
times pufiness  beneath  the  eyes  indicates  a  hematopoietic 
dyscrasia  or  kidney  malfunction. 

It  should  be  emphasized  here,  however,  that  the  above 
popularly  accepted  indications  of  the  anemia  in  malignant 
disease  only  appear  when  the  neoplasm  is  well  advanced. 
Latent  or  early  cancer  may  exist  a  considerable  time  before 
readily  recognized  systemic  damage  results.  This  is 
especially  the  case  in  carcinoma  of  the  stomach.     Well 

319 


320  CANCER  OF  THE  STOMACH 

confined  ulcera  carcinomatosa  or  incipient,  primary  can- 
cerous change  in  the  gastric  Uning  may  produce  few  ex- 
ternal signs  indicative  of  their  presence.  Moreover,  in 
such  event,  even  most  carefully  performed  blood  analyses 
may  fail  to  demonstrate  any  suspicious  cellular  or  serologic 
anomaly. 

The  causes  of  anemia  in  gastric  cancer  appear  to  be 
multiple.  It  is  only  an  exhibition  of  our  lack  of  exact  knowl- 
edge which  permits  the  statement  that  the  growth  of  a  neo- 
plasm exerts  deleterious  influences  upon  normal  metabolism. 
When  physiologic  and  biologic  chemists  have  discovered 
what  factors  are  concerned  in  normal  metabolism,  it  may 
then  be  possible  to  estimate  the  precise,  constitutional 
significance  of  what  are  now  considered  by-products  of  a 
malignant  tumor's  cellular  activity.  That  foreign  sub- 
stances emanate  from  cancer  tissue  seems  quite  probable. 
The  researches  of  Gay,  Ascoli,  Abderhalden,  Weil,  Jobling, 
W.  Hamburger  and  others  appear  to  demonstrate  that  in 
the  development  of  a  neoplasm  some  ferment-like  body  or 
bodies  are  manufactured  or  increased  locally.  These  may 
exert  pernicious  effects  by  stimulating  cell  proliferation,  by 
overflowing  into  the  blood  or  the  lymph  streams,  and  thus 
acting  as  potential,  if  not  actual,  foreign  substances,  or,  by 
acting,  locally  or  generally  upon  already  damaged  or  bio- 
logically immature  tissue,  they  may  liberate  end-digestion 
products,  which  affect  the  body  economy  either  by  their 
presence  in  excessive  amounts  or  by  their  entrance  into  the 
body  fluids  at  a  non-physiologic  point.  While  there  is  no 
direct  evidence  that  products  of  malignant  growths  directly 
injure  the  blood-forming  centers,  there  is  considerable  proof 
that  when  cancer  has  become  well  established,  the  prod- 
ucts of  the  hematopoietic  organs  are  of  inferior  quality, 
and  not  rarely,  of  diixdnished  quantity. 


THE   BLOOD    IN    GASTRIC    CANCER  321 

Other  factors  likely  to  be  of  importance  in  the  causation 
of  anemia  in  gastric  cancer  are  secondary  infection,  starva- 
tion, exhaustion  (from  vomiting,  diarrhea  or  prolonged 
pain),  hemorrhage,  certain  psychic  abnormalities,  or  defi- 
cient function  of  the  kidneys,  liver  or  the  pancreas.  The 
development  of  extensive  metastases  sometimes  exerts 
pernicious  effects  upon  the  blood  picture. 

Blood  changes  observed  in  gastric  cancer  resolve  them- 
selves into  a  consideration  of  the  deviations  from  the  normal 
of  (1)  formed  elements  (erythrocytes,  leucocytes)  and  (2) 
the  blood  plasma. 

(1.)  DEVIATIONS  FROM  THE  NORMAL    OF  THE  FORMED  BLOOD 

CONSTITUENTS 

Quantitative  Changes  in  Erythrocytes. — ^The  average  red 
blood  cell  count  of  129  cases  of  gastric  cancer  examined  by 
Cabot  is  given  as  4,018,000  cells.  In  more  than  75  per 
cent,  of  these  cases  the  diagnosis  was  confirmed  by  operation 
or  by  autopsy.  The  cases  remaining  were  clinically  cancer 
of  the  stomach. 

The  average  red  count  from  59  cases  studied  by  Osier 
and  McCrae  was  3,712,186.  Their  cases  were  clinically, 
or  at  post-mortem,  cancerous. 

In  our  series,  there  were  267  instances  of  the  disease  where 
accurate  red  cell  counts  were  made.  Table  26  shows  the 
summary  of  these  investigations. 

It  will  be  noted  that  the  average  erythrocyte  count  was 
4,380,000.  This  is  a  figure  rather  higher  than  the  average 
given  by  other  investigators.  It  is  to  be  explained  partly 
on  the  basis  that  many  of  our  cases  were  diagnosed  very 
early  (often  at  laparotomy  and  then,  microscopically)  or 
the  large  number  of  patients  returns  a  fairer  average  than 
does  a  relatively  small  list.     The  minimum  erythrocyte 


322 


CANCER   OF   THE    STOMACH 


Table  26 


Red  cell  count 


Per  cent. 


Below  1,000,000 

From  1,000,000  to  2,000,000. 
From  2,000,000  to  3,000,000. 
From  3,000,000  to  4,000,000. 
From  4,000,000  to  5,000,000. 
From  5,000,000  to  6,000,000. 
From  6,000,000  to  7,000,000. 


Average  4,380,000  for . 


Showing  Variations  in  Erythrocyte  Count  in  267  Cases  of  Gastric  Cancer 
(Author). 

count  was  860,000  cells.  This  was  returned  in  a  case  of 
inoperable  tumor  with  ascites  and  extensive  general  metas- 
tases. The  maximum  red  cell  count  was  6,328,000  cells. 
This  was  from  a  patient  with  inoperable  cancer  of  the  lesser 
curvature  and  the  body  of  the  stomach.  There  were 
metastases  to  the  rectal  shelf  and  the  peritoneum.  It  is  thus 
seen  that  while  low  erythrocyte  counts  may  be  returned 
in  instances  where  there  are  hopeless  gastric  neoplasms, 
high  counts  may  likewise  be  obtained  late  in  the  progress 
of  the  disease. 

In  more  than  91  per  cent,  of  our  cases  the  red  cell  count 
lay  between  3,000,000  and  7,000,000  cells.  In  nearly 
50  per  cent,  the  counts  fell  between  4,000,000  and  5,000,000 
cells. 

The  Influence  of  Metastases. — Our  experience  is  sum- 
marized in  Tables  27  and  28. 

Study  of  these  two  tables  demonstrates  that  of  the  267 
cases  of  gastric  cancer  in  which  erythrocyte  counts  are 
available,  in  79.9  per  cent,  there  were  gross  or  microscopic 
metastases;  of  those  instances  in  which  metastases  were 
present  the  red  cell  count  was  included  between  limits  of 
from  3,000,000  to  6,000,000  cells  in  90.4  per  cent,  where 


THE    BLOOD    IN    GASTRIC    CANCER 


323 


Table  27 


Range  of  erythrocyte 
counts 

Metastases 

(number  of 

cases) 

+ 

Metastases 

(number  of 

cases) 

+  + 

Metastases 

(number  of 

cases) 

+  +  + 

Free  Fluid 

(number  of 

cases) 

Below  1,000,000  

2 

1,000,000  to  2,000,000. 
2,000,000  to  3,000,000. 
3,000,000  to  4,000,000. 
4,000,000  to  5,000,000. 
5,000,000  to  6,000,000. 
6,000,000  to  7,000,000. 

3 

6 

23 

45 

17 

2 

1 

20 

16 

3 

9 
34 
17 

5 

Summaries 94                      60 

42 

7 

To  Demonstrate  Relation  of  Erythrocyte  Count  to  Metastasis  in  Gastric 
Cancer  (Author). 

Table  28 


Range  of  erythrocyte  counts 


Number  of 
cases 


Per  cent. 


Below  1,000, 
1,000,000  to 
2,000,000  to 
3,000,000  to 
4,000,000  to 
5,000,000  to 
6,000,000  to 


000 

2,000,000. 
3,000,000. 
4,000,000. 
5,000,000. 
6,000,000. 
7,000,000. 


9 
18 
28 

9 


13.9 
28.1 
43.1 
13.9 


Summary. 


64 


99.0 


Demonstrating  Erythrocyte  Counts  in  Cases  where  no  Metastases  Existed 
(Author) . 

metastases  were  limited  in  extent;  in  100  per  cent,  where 
metastases  were  moderate  in  degree;  in  88  per  cent,  where 
metastasis  to  lymph  glands  was  very  extensive,  and  in 
71  per  cent,  where  free  abdominal  fluid  occurred  with  or 
without  other  evidences  of  metastasis.  The  average  per- 
centage of  cases  showing  metastasis  where  the  red  cell 
count  lay  between  3,000,000  and  6,000,000  cells  was  87.3. 

In  the  64  cases  in  which  no  metastases  could  be  demon- 
strated, in  85.1  per  cent,  the  erythrocyte  count  lay  between 
3,000,000  and  6,000,000  cells. 


324 


CANCER   OF   THE    STOMACH 


It  would  seem  from  the  above  analysis  of  267  proved  cases 
of  gastric  cancer,  that  diminution  in  red  cell  count  depends 
not  wholly  upon  the  development  of  metastases.  On  the 
contrary,  a  large  group  of  cases  with  extensive  metastases 
have  higher  average  erythrocyte  counts  than  have  those 
free  from  metastases. 

Quantitative  Changes  in  Hemoglobin. — Osier  and  Mc- 
Crae  (loc.  cit.)  record  hemoglobin  estimations  in  52  instances 
of  cancer  of  the  stomach.  These  cases  returned  an  average 
hemoglobin  of  49.9  per  cent,  and  an  average  color  index  of 
0.63  (Cabot). 

We  have  records  of  hemoglobin  estimations  (Dare  method 
for  the  majority)  upon  454  cases.  Table  29  shows  the 
variations  in  the  readings. 

Table  29 


Hemoglobin  reading,  per  cent. 

Number  of  cases 

Per  cent. 

Below  20 

Between  20-30 

9 
31 

76 
64 
82 
77 
106 
9 

1.5 

Between  30-40 

6.8 

Between  40-50 

16  7 

Between  50-60 

14.6 

Between  60-70 

18  1 

Between  70-80 

16  9 

Between  80-90 

23  4 

Between  90-100 

1.9 

Total 

454 

99  9 

Showing  the  Variation  of  Hemoglobin  Reading  in  454  Cases  of  Gastric 
Cancer  (Author). 

It  will  be  noted  that  in  72.2  per  cent,  of  the  patients,  the 
hemoglobin  ranged  between  50  per  cent,  and  100  per  cent., 
that  in  42.2  per  cent,  it  was  above  70  per  cent,  and  more  than 
1  out  of  every  3  cases  (38.5  per  cent.)  had  a  hemoglobin 
reading  between  50  per  cent,  and  80  per  cent.  The  aver- 
age hemoglobin  percentage  for  the  series  was  64.3  per  cent. 


THE    BLOOD    IN    GASTRIC    CANCER 


325 


The  minimuin  was  25  per  cent,  and  the  maximum  95  per 
cent. 

The  Effect  of  Metastases. — In  this  respect  we  have  studied 
hemoglobin  records  in  a  manner  similar  to  that  above 
described  when  considering  the  erythrocyte  counts.  Tables 
30  and  31  demonstrate  the  variations  in  hemoglobin  when 
metastases  were  present  and  when  they  were  absent. 

Table  30 


Hemoglobin  percentage 

Metastases 
+ 

Metastases 

+    + 

Metastases 
+    +    + 

Free  fluid 

10-20 

20-30 

5 
5 

3 

8 

1 

30-40 

12 

1 

40-50 

20 

26 

6 

0 

50-60 

24 

12 

11 

4 

60-70 

43 

15 

11 

0 

70-80 

13 

14 

18 

2 

80-90 

46 

32 

12 

1 

90-100 

5 

2 

Summary 

163 

111 

69 

9 

Demonstrating  Variations  in  Hemoglobin  in  Gastric  Cancer  Percentage 
when  Metastases  are  Present  (Author). 


Table  31 


Total. 


Hemoglobin  percentage 

Number  of  cases 

10-20 

20-30 

30-40 

5 

40-50 

24 

50-60 

13 

60-70 

13 

70-80 

30 

80-90 

15 

90-100 

2 

102 


Demonstrating   Variations  in   the  Hemoglobin  in  Gastric  Cancer  when 
Metastases,  are  Absent  (Author). 


326  CANCER   OF   THE    STOMACH 

Of  the  cases  in  which  metastases  were  proven,  hemoglobin 
was  above  50  per  cent,  in  131  cases  or  80.4  per  cent,  of  those 
where  there  was  shght  lymph-gland  invasion;  in  75  cases  or 
67.5  per  cent,  where  there  were  moderate  metastases; 
in  52  cases  or  75.3  per  cent,  where  there  was  extensive 
lymphatic  involvement,  and  in  7  cases  or  77.7  per  cent, 
where  there  was  ascitic  fluid.  In  other  words,  of  352 
cases  (77.5  per  cent.)  showing  metastases  the  hemoglobin 
was  50  per  cent,  or  higher  in  75.2  per  cent. 

There  were  102  cases  (22.5  per  cent.)  where  there  were  no 
metastases.  In  this  group  hemoglobin  was  50  per  cent,  or 
higher  in  73  instances  or  71.5  per  cent. 

It  would  seem  from  the  above  analysis  that  low  hemo- 
globin percentages  have  relatively  little  value  toward  in- 
dicating the  presence  or  absence  of  metastases. 

Color-index. — In  the  blood  examinations  of  267  consecu- 
tive cases  the  average  color  index  was  0.73.  The  minimum 
index  was  0.32  and  the  maximum  0.97. 

Shape  and  Size  of  Erythrocytes.^ — In  well-advanced  gas- 
tric cancer,  when  the  hemoglobin  is  below  75  per  cent.,  it  is 
not  uncommon  to  find  red  blood  cells  that  exhibit  wide 
variations  in  shape  and,  occasionally,  in  size.  The  studies 
of  Osier  and  McCrae  and  Cabot  {loc.  cit.)  seem  to  show  that 
in  malignant  disease  macrocytes  are  unusual  findings  and 
that  the  cancer  anemia  is  of  the  type  common  to  chlorosis. 
While  this  holds  generally  true,  there  are  interesting  ex- 
ceptions. Our  records  detail  17  blood  studies  where  mac- 
rocytes were  found  and  eight  instances  in  which  megalo- 
blasts  are  recorded.  In  23  cases  normoblasts  were  noted. 
We  never  observed  macrocytes  or  nucleated  erythrocytes 
where  the  hemoglobin  was  higher  than  70  per  cent,  or  the 
red  cell  count  above  3,500,000. 

Of  204  blood  analyses  where  definite  record  of  red-cell 


THE   BLOOD    IN    GASTRIC    CANCER  327 

variations  in  shape  and  size  were  recorded,  in  82  instances 
(40.3  per  cent.)  the  variation  was  noted  as  being  ''sHght," 
in  92  cases  (45.09  per  cent.)  as  of  ''moderate  degree,"  and 
in  30  instances  (14,7  per  cent.)  as  ''marked." 

Poikilocytosis,  blood  "shadows,"  or  degenerative  forms 
are  quite  common  in  the  blood  smears  from  well-established 
gastric  cancer.  From  the  blood  of  early  cases  they  may  be 
wholly  absent.  Not  infrequently,  these  variations  in 
erythrocyte  structure  seem  out  of  all  reasonable  proportion 
to  the  red  cell  count,  or  the  hemoglobin.  We  have  not 
been  able  to  establish  any  definite  cause  for  this  phenome- 
non. "Cancerous  poisoning"  of  the  blood-forming  centers 
does  not  furnish  a  satisfactory  explanation.  In  view  of 
work  done  upon  isolysins  in  malignant  disease,  it  might 
be  suggested  that  the  rate  of  hemolysis  was  accelerated  in 
gastric  cancer. 

CHANGES  IN   THE   LEUCOCYTES 

Quantitative. — Summarizing  leucocyte  counts  in  23  cases 
of  gastric  cancer,  DaCosta  (quoted  by  Cabot)  found  an 
average  count  of  8,100  cells.  The  minimum  was  1,000 
cells  and  the  maximum  14,000  cells.  Cunliffe's  records  of 
10  cases  of  the  disease  reveal  an  average  white  cell  count 
of  17,280,  with  a  minimum  of  5,200  cells  and  a  maximum  of 
36,800  cells.  Cabot  {loc.  cit.)  analyzed  the  leucocytes  in 
235  cases  of  cancer  of  the  stomach.  His  study  shows  an 
average  count  of  10,600  cells.  The  minimum  count  was 
between  3,000  and  4,000  cells  and  the  maximum  between 
30,000  and  40,000  cells. 

A  review  of  the  literature  demonstrates  that  high  leuco- 
cyte counts  are  not  uncommon  in  rapidly  growing  gastric 
neoplasms.  The  ratio  between  white  and  red  cells  may  be 
greatly  reduced.     Cabot  reports  a  case  of  Welch's  in  which 


328 


CANCER    OF   THE    STOMACH 


the  ratio  of  white  to  red  cells  was  as  1:25  instead  of  the 
normal  ratio  of  as  1 :  750. 

Of  our  series  of  gastric  cancers,  we  have  leucocyte  counts 
in  261  instances.  The  average  count  was  11,270  cells. 
The  minimum  was  4,200  cells  and  the  maximum  36,200 
cells.  Table  32  groups  the  cases  according  to  cell-count 
range. 

Table  32 


Leucocytes 


Between 
Between. 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 
Between 


4,000-  5,000. 

5,000-  6,000. 

6,000-  7,000. 

7,000-  8,000. 

8,000-  9,000. 

9,000-10,000. 
10,000-11,000. 
11,000-12,000. 
12,000-13,000. 
13,000-14,000. 
14,000-15,000. 
15,000-16,000. 
16,000-17,000. 
17,000-18,000. 
18,000-19,000. 
19,000-21,000. 
21,000-37,000. 


Number  of  cases        Percentage 


15 

5.7 

17 

6.5 

33 

12.7 

56 

21.4 

31 

11.5 

27 

10.3 

18 

6.9 

15 

5.7 

6 

2.3 

16 

6.1 

9 

3.4 

3 

1.1 

3 

1.1 

2 

0.76 

3 

1.1 

5 

1.9 

2 

0.76 

Average  11,270. 


261 


99.22 


Demonstrating  Variations   in  Leucocyte   Count  of  261  Cases  of  Gastric 
Cancer  (Author). 


Study  of  the  table  shows  that  55.9  per  cent,  of  all  cases 
had  leucocyte  count  between  6,000  and  10,000  cells;  that 
more  than  4  out  of  5  of  all  the  cases  had  leucocytes  between 
6,000  and  14,000  cells;  that  not  quite  1  out  of  every  4  cases 
(24.22  per  cent.)  had  white  cell  count  above  the  average 
of  the  series,  and  that  approximately  3  out  of  4  cases  had 
white  cell  count  below  the  average  for  the  series. 


THE    BLOOD    IN    GASTRIC    CANCER  329 

The  complete  blood  count  in  the  case  with  minimum 
leucocyte  count  was  as  follows : 

White  blood  corpuscles,  4,200;  red  blood  corpuscles, 
1,830,000;  hemoglobin,  30  per  cent. 

Differential  count  of  leucocytes:  Polymorphonuclears, 
67.7  per  cent.;  small  lymphocytes,  27.3  per  cent.;  large 
lymphocytes,  3.0  per  cent.;  eosinophiles,  2.0  per  cent.; 
transitionals,  0.7  per  cent. 

There  was  noted  ''moderate"  variation  in  the  size  and 
shape  of  the  individual  red  blood  cells.  Pathologically,  the 
case  was  one  of  inoperable  cancer  of  the  lesser  curvature  and 
the  body  of  the  stomach  with  extensive  metastases  and 
free  abdominal  fluid. 

The  complete  blood  count  in  the  case  with  the  maximum 
leucocyte  count  was  as  follows : 

White  blood  corpuscles,  36,200;  red  blood  corpuscles, 
4,980,000;  hemoglobin,  82  per  cent. 

The  differential  count  of  leucocytes:  polymorphonu- 
clears, 81.3  per  cent.;  small  lymphocytes,  13.3  per  cent.; 
large  lymphocytes,  3.0  per  cent.;  eosinophiles,  1.0  per  cent.; 
transitionals,  0.3  per  cent.;  myelocytes,  1.3  per  cent. 

There  was  recorded  ''marked"  variation  in  the  size 
and  shape  of  the  individual  erythrocytes. 

Surgically,  this  case  was  one  of  extensive  carcinoma  of 
the  posterior  wall  of  the  stomach,  with  invasion  of  the  pan- 
creas and  extensive  lymph-gland  metastases. 

It  has  been  held  that  leucocytosis  in  gastric  cancer  is  an 
index  to  the  extent  of  the  metatases,  the  rapidity  of  growth 
of  the  tumor,  or  such  complications  in  the  course  of  the 
ailment,  as  hemorrhage  or  perforation.  The  validity  of 
these  claims  has  been  questioned  by  Osier  and  McCrae 
and  by  Cabot. 

For  the  purpose  of  studying  the  effect  of  metastases  upon 


330 


CANCER   OF   THE    STOMACH 


the  leucocyte  count,  we  have  compiled  from  our  records 
Tables  33  and  34. 

Table  33 


Summary . 


84 


58 


54 


Leucocyte  variations 

Metastases 

(number  of 

cases) 

+ 

Metastases 

(number  of 

cases) 

+  + 

Metastases 

(number  of 

cases) 

+  +  + 

Ascites 

(number  of 

cases) 

4  000         5  000 

7 

3 
0 

3 
3 

c;  non  -   6  000                    s 

6,000-    7,000 

7,000  -    8,000 

8,000-    9,000 

9,000-10,000 

10  000  -  11  000 

5 
13 

2 
3 
s 

12  2 

13  16 

3 

12 

3 

5 

10 
10 

3 

11,000-12,000 7 

12,000-13,000 5 

13,000-14,000 11 

14,000-15,000 9 

15,000-16,000 2 

16,000-17,000 1 

17  000  -  18,000.                

5 

1 

2 

2 
3 
1 

18  000  -  19  000              '           

19,000  -  21,000.             '           2 

2 

21  000  -  37  000              1           1 

1 

Showing   the    Relation   of  Leucocyte  Counts  to  Metastases  in  Gastric 
Cancer  (Author). 

Table  34 


Leucocyte  variations 


Number  of  cases 


4,000-  5,000 

2 

5,000-  6,000 

6 

6,000-  7,000 

14 

7,000-  8,000 

14 

8,000-  9,000 

13 

9,000-10,000 

2 

10,000-11,000 

7 

11,000-12,000 

3 

12,000-13,000 

1 

Total 

62 

Showing  Variations  in  Leucocyte    Counts  in  Cases  of  Gastric    Cancer 
without  Metastases  (Author). 


THE   BLOOD    IN    GASTEIC    CANCER  331 

Certain  facts  of  interest  are  brought  out  by  a  study  of 
these  tables.  It  will  be  observed  that  there  are  199  cases 
where  metastases  occurred,  and  62  instances  free  from  met- 
astases. Of  the  cases  showing  metastases  there  were  84 
instances  (42.2  per  cent.)  where  the  involvement  was  small. 
Of  this  number  the  leucocyte  count  was  10,000  cells  or 
below  in  45.2  per  cent,  or  19  per  cent,  of  the  entire  group 
showing  metastases.  There  were  58  cases  (29  per  cent.) 
showing  moderate  degree  of  metastasis.  Of  this  number 
74  per  cent,  exhibited  white  cell  count  of  10,000  cells  or 
below  (21.6  per  cent,  of  entire  group).  There  were  54 
cases  (22  per  cent.)  with  extensive  metastases.  Of  this 
group  81  per  cent,  had  leucocyte  count  of  10,000  cells  or 
below  (26  per  cent,  of  metastasis  class).  Of  the  cases 
where  ascites  was  demonstrated  100  per  cent.  (1.6  per  cent, 
of  group)  had  white  cell  count  of  10,000  or  below.  Of  all 
the  cases  showing  metastases  13.6  per  cent,  had  leucocytosis 
of  15,000  or  above. 

Of  the  entire  number  of  cases  with  metastases,  leucocytes 
averaged  10,000  cells  or  below  in  22.6  per  cent.  In  this 
figure  the  cases  classed  under  ascites  are  not  included.  The 
comparative  average  for  the  different  groups  is  66.5  per 
cent. 

In  the  group  of  gastric  cancers  without  metastases  (62 
cases)  the  leucocytes  were  at  or  below  10,000  in  82  per  cent. 
There  were  no  instances  where  leucocytes  were  higher  than 
13,000  cells. 

From  a  study  of  the  above  analysis,  it  will  be  seen  that 
while  more  than  4  out  of  5  cases  of  gastric  cancer  without 
metastases  making  up  our  series  had  leucocyte  count  of 
10,000  cells  or  below,  an  average  of  but  2  out  of  3  cases  of 
the  different  groups  showing  grades  of  metastasis  had  leu- 
cocyte count  so  low.     Of  the  whole  number  exhibiting 


332  CANCER  OF  THE  STOMACH 

metastases  the  white  cell  count  was  10,000  cells  or  below  in 
but  rather  more  than  1  out  of  5  cases. 

Digestion  Leucocytosis. — We  have  no  original  observa- 
tions to  record.  Miiller  and  Capps  state  that  digestion 
leucocytosis  is  absent  in  more  than  80  per  cent,  of  gastric 
cancers.  Osier  and  McCrae  (loc.  cit.)  claim  that  ''the 
presence  of  digestion  leucocytosis  is  too  uncertain  to  be  of 
much  assistance  in  diagnosis."  Recently,  Bonhoff  has 
made  a  study  of  this  phase  of  the  leucocyte  count  and  claims 
that  the  observation  of  digestion  leucocytosis  is  a  valuable 
clinical  aid  in  the  differentiation  between  benign  peptic 
ulcer  and  ulcus  carcinomatosum. 

The  Qualitative  Variation  in  the  Leucocytes. — In  our 
series  we  have  records  of  differential  leucocyte  counts  in 
160  cases.     The  following  facts  are  of  interest: 

Poly  nuclear  leucocytes  averaged  73.2  per  cent.  The 
minimum  was  56  per  cent,  and  the  maximum  86.4  per  cent. 

Small  lymphocytes  averaged  19.1  per  cent.  The  minimum 
was  9.7  per  cent,  and  the  maximum  37.5  per  cent. 

Large  lymphocytes  averaged  3.41  per  cent.  The  minimum 
was  0.7  per  cent,  and  the  maximum  13  per  cent. 

Basophile  leucocytes  averaged  1.28  per  cent.  The  mini- 
mum was  0.3  per  cent,  and  the  maximum  5  per  cent. 

Transitional  leucocytes  averaged  1.58  per  cent.  The 
minimum  was  0.3  per  cent,  and  the  maximum  6  per  cent. 

Myelocytes  were  observed  in  43  cases  (26.8  per  cent.) 
where  differential  counts  were  made.  The  average  was 
1.27  per  cent.  The  minimum  was  0.3  per  cent.,  and  the 
maximum  3.3  per  cent.  Myelocytes  were  frequently  noted 
where  the  red  cell  count  was  above  4,500,000  cells,  but  "were 
observed  in  no  instance  where  the  hemoglobin  was  higher 
than  75  per  cent.  The  lowest  myelocyte  percentage  (0.2 
per  cent.)  was  seen  when  the  leucocyte  count  was  7,200. 


THE   BLOOD    IN    GASTKIC    CANCER  333 

The  hemoglobin  was  30  per  cent,  and  the  red  cell  count 
1,830,000.  The  highest  myelocyte  count  was  observed 
where  the  leucocytes  totaled  6,900.  In  this  case  the  hemo- 
globin was  40  per  cent,  and  the  red  cell  count  4,110,000. 

Eosinophiles  were  noted  in  109  of  the  differential  counts 
(67  per  cent.).  The  average  was  4.01.  The  minimum  was 
0.3  per  cent.     The  maximum  was  7.7  per  cent. 

In  the  case  with  the  minimum  percentage  of  eosinophiles, 
the  leucocytes  were  5,600,  the  erythrocytes  3,260,000  and 
the  hemoglobin  38  per  cent. 

In  the  case  with  the  maximum  percentage  of  eosino- 
philes, the  leucocytes  were  7,200,  the  red  blood  cells  4,180,- 
000  and  the  hemoglobin  65  per  cent. 

In  none  of  our  cases  of  relatively  high  eosinophilia  could 
we  attribute  the  increase  to  such  ills  as  lung  affections, 
skin  disease,  high  fever,  medication,  severe  hemorrhage,  or 
disease  of  the  genito-urinary  tract. 

(2)  DEVIATIONS  FROM  THE  NORMAL  AS  SHOWN  BY  THE 
BLOOD  SERUM 

The  gastric  neoplasm  can  quite  properly  be  regarded  as 
itself  being  a  parasite  with  the  patient  a  host.  From 
etiologic,  histologic  and  clinical  study,  it  would  seem  that 
the  host  has  a  form  of  protective  mechanism.  If  such  did 
not  exist,  it  would  be  inconceivable  why  all  members  of  the 
human  family  do  not  die  of  cancer,  or  why  certain  individ- 
uals live  longer  than  do  others  when  affected  with  the  same 
histologic  type  of  cancer  in  relatively  the  same  part  of  the 
stomach.  It  would  appear  that  the  body's  protective 
mechanism  is  similar  in  kind  against  all  histologic  forms  of 
cancer.  The  strength  of  this  defensive  power  seems  not 
only  to  vary  in  different  individuals,  but  may  exhibit 
alterations  in  degree  in  the  same  individual  at  different 
times. 


334  CANCER  OF  THE  STOMACH 

In  the  human,  at  least,  the  body's  defensive  abiHty  ap- 
pears to  rest  mainly  upon  ferment-like  agents.  These 
agents  are  evidently  essential  components  or  products  of 
protoplasm.  They  represent  the  most  highly  refined  end- 
results  of  intercellular  or  intracellular  biochemic  change. 
These  cell  products,  while  apparently  rigidly  specific  in 
their  function,  appear  to  act  in  a  similar  manner.  These 
defensive  substances  are  doubtless  present  in  both  cellular 
and  fluid  structures  of  the  body.  There  is  reason  to  sup- 
pose that  in  blood  serum,  lymph  and  spinal  fluid  protective 
agents  against  cancer  are  constantly  present.  If  malignant 
neoplasms  behave  as  do  other  parasites  or  foreign  bodies 
when  they  invade  their  hosts,  it  would  seem  that  the  added 
demand  for  a  specific  defensive  agent  against  such  might  be 
measurable  by  biochemic  study  of  the  body  fluids,  particu- 
larly of  the  blood  serum  and  the  blood  cells.  Much  re- 
search along  these  lines  has  been  carried  on.  While  thus 
far  there  has  been  isolated  no  absolutely  specific  defensive 
agent  against  cancer,  it  would  seem  that  certain  biologic 
phenomena  of  blood  sera  indicate  a  broad,  basic  principle 
of  defence,  the  exact  significance  of  which  has  not  yet  been 
established.  But  a  few  aspects  of  the  mechanism  of  this 
protective  agent  against  cancer  in  general  can  be  considered 
in  a  special  monograph  upon  cancer  of  the  stomach. 

The  Hemolytic  Reaction.^ — In  1902,  Lang  showed  that 
in  advanced  cases  of  cancer,  the  erythrocytes  were  very 
resistant  to  anisotonic  solutions  of  sodium  chloride.  In 
1908,  Weil  demonstrated  that  the  blood  serum  of  dogs 
harboring  experimental  lymphosarcoma  was  lytic  for  the 
erythrocytes  of  non-sarcomatous  dogs,  but  not  for  the  red 
blood  cells  of  other  dogs  harboring  like  malignant  tumors. 
Under  certain  limitations  this  observation  appeared  to 
be  of   diagnostic  worth  in  human  cancer.     To  Krida,  we 


THE   BLOOD    IN    GASTKIC    CANCER  335 

are  indebted  for  a  detailed  description  of  the  method  of 
performing  the  test,  and  for  a  resume  of  its  diagnostic 
worth. 

Hemolysis  in  the  Diagnosis  of  Cancer. — Krida  employs  the 
following  technique:  The  blood  for  the  test  is  obtained  by 
puncturing  one  of  the  superficial  veins  after  tying  a  tight 
bandage  around  the  arm  above  the  point  of  puncture. 
About  10  cc.  are  withdrawn;  of  this  about  1  cc.  is  added  to 
a  centrifuge  tube  which  has  been  previously  half  filled  with 
a  normal  salt  solution  to  which  1  per  cent,  sodium  citrate 
has  been  added,  and  immediately  centrifuged  to  throw  down 
the  cells.  Or  the  cells  may  be  obtained  by  defibrinating  a 
small  quantity  of  blood  by  shaking  with  glass  beads.  The 
rest  of  the  blood  is  placed  in  a  sterile  test-tube,  slanted  and 
placed  in  the  ice  chest  to  clot  and  allowed  to  remain  there 
for  12  to  24  hours.  The  cells  as  previously  obtained  are 
washed  2  or  3  times  in  salt  solution,  and  then  made  up  to 
a  5  per  cent,  emulsion  with  salt  solution  and  placed  in  the 
ice  chest  until  ready  for  use.  Cells  and  serum  are  obtained 
in  a  similar  manner  from  two  normal  individuals  to  act  as 
controls  and  are  also  placed  in  the  ice  chest  until  ready  for 
use.  Several  pathological  sera  may  of  course  be  tested 
with  these  two  controls. 

When  the  test. is  ready  to  set  up,  the  hemolysis  tubes  are 
sterilized,  then  washed  in  normal  salt  solution.  As  many 
different  combinations  of  cells  and  serum  as  possible  are 
made,  using  5  cc.  of  each,  and  the  plan  of  the  mixtures  noted. 
The  simplest  procedure  is  to  begin  with  one  cell  emulsion, 
placing  5  cc.  in  as  many  tubes  as  there  are  kinds  of  sera, 
and  adding  to  each  tube  5  cc.  of  the  various  sera.  As  an 
additional  control,  a  preparation  with  cells  and  salt  solution 
and  cells  and  sterile  water  might  be  made;  the  hemolysis 


336 


CANCER   OF   THE    STOMACH 


in  the  tube  containing  the  sterile  water  will,  of  course,  be 
complete. 

The  rack  containing  the  test  is  now  placed  in  the  incu- 
bator at  37°  C.  for  2  hours.  Some  make  an  entire  duplicate 
set  and  heat  it  in  the  water-bath  for  10  minutes  at  55°  C. 
before  incubating  (to  destroy  complement).  At  the  end  of 
2  hours,  the  tests  are  placed  in  the  ice  chest  for  12  hours, 
and  the  results  are  then  read  off  by  some  person  who  does 
not  know  the  key  to  the  plan  of  mixtures.  Hemolysis  is 
apparent  by  a  pink  or  red  discoloration  of  the  supernatant 
fluid  in  the  test-tubes. 

If  the  hemolysis  test  for  cancer  is  positive  the  cancer 
serum  should  have  hemolyzed  the  cells  of  both  the  normal 
controls.  A  reverse  hemolysis,  i.e.,  normal  serum  hemo- 
lyzing  pathologic  cells  is  considered  characteristic  of 
tuberculosis  by  Crile,  but  in  this  the  results  of  the  other 
observers  are  almost  uniformly  negative. 

The  following  table  presents  a  summary  of  the  results 
with  the  hemolytic  reaction: 

Table  35 


Total 

Carcinoma 

Benign 

tumors 

Miscella- 
neous 
diseases 

Reverse 
reactions 

Normals 

Excised 

carcinoma 

without 

clinical 

recurrence 

Weil 

82 
591 

33 

35 
109 

75 

301 
328 
158 

100 

31 

164 
11 
35 
22 
25 

42 
73 
31 

38 

PL  15 
P1.141 
PL  10 
PL  12 
PL     8 
PL  18 

PL  36 
PL  35 
PL  14 

PL  28 

3 

55 

4 

PL     1 

PL  00 
PL     0 

42 
71 
18 

PL     9 
PL     7 
PL     2 

6 
211 

PI.   10 
PL     0 

Crile 

Arnold 

52 

PL  49 

37 

PL     0 

Jane way 

Whittemore.  .  . 

32 

40 

106 

103 

55 

40 

PL     6 
PL     4 

PL  17 
PL     0 
PL     9 

PL  20 

8 

PL     4 

39 
10 

85 

112 

24 

22 

PL     7 
PI.     1 

PL     4 
PI.     0 
PI.     1 

PL     1 

Blumgarten...  . 

Johnston  and 

Canning 

Richartz 

14 

PL     0 

43 
40 
45 

PL     7 
PL  21 
PL     2 

3 

PI.     0 

Smithies 

3 

PL     0 

Epstein     and 
Ottenberg. . . . 

1,812 

472 
pe 

PL317 
67 

r  cent. 

79 

pe 

PL     1 

IH 
r  cent. 

507 
pe 

PL  74 
15 
r  cent. 

188 
pe 

PL  83 

44 
r  cent. 

509 
pe 

PI.   14 
2.6 
r  cent. 

40 
pe 

PL     0 
0 
r  cent. 

Showing  the  Diagnostic  Significance  of  the  Hemolytic    Test   in   Cancer 
(Krida). 


THE   BLOOD    IN    GASTRIC    CANCER  337 

Of  a  total  of  1,812  observations  reported  by  ten  different 
workers,  472  cases  were  carcinoma;  of  these,  317  or  67  per 
cent,  gave  positive  hemolytic  reactions.  Seventy-nine  were 
benign  tumors,  of  which  1  or  13^^  per  cent,  were  positive. 

Five  hundred  seven  observations  were  made  in  a 
variety  of  diseases,  74  or  15  per  cent,  of  which  presented 
positive  reaction. 

Five  hundred  nine  observations  were  made  on  nor- 
mal individuals,  14  or  2.6  per  cent,  were  positive. 

In  40  post -operative  carcinoma  cases  without  clinical 
recurrence,  the  reaction  was  uniformly  negative. 

One  hundred  eighty-eight  tests  were  performed  on  tu- 
berculosis patients;  of  these,  82  or  44  per  cent,  presented 
''reverse"  hemolysis. 

Skin  Reaction. — The  basis  of  the  skin  reactions  for 
carcinoma  is  the  subcutaneous  injection  into  the  forearm 
of  about  5  minims  of  a  20  per  cent,  suspension  in  physio- 
logical salt  solution  of  red  blood  cells  obtained  from  a 
normal,  healthy  individual. 

The  quantity  of  blood  necessary  varies,  of  course,  with 
the  number  of  reactions  to  be  carried  out.  For  10  or  12 
reactions,  2  to  3  cc.  are  obtained  as  described  previously. 
Sufficient  blood  for  two  or  three  tests  maybe  obtained  by 
simply  puncturing  the  finger  and  allowing  a  dozen  drops  to 
flow  into  a  centrifuge  tube  half  full  of  salt-citrate  solution. 
This  is  immediately  centrifuged,  washed  3  times  as  pre- 
viously described,  and  made  into  a  20  per  cent,  suspension 
in  physiological  salt  solution.  The  suspension  is  placed 
at  0°  C.  for  24  to  48  hours  and  is  then  ready  for  use.  A 
convenient  method  of  keeping  this  suspension  until  ready 
for  use  is  to  draw  up  a  sufficient  quantity  for  individual  tests 
into  pipettes  and  seal  the  ends.  The  suspension  does  not 
keep  longer  than  5  days,  and  one  should  see  that  no  hemol- 

22 


338  CANCER  OF  THE  STOMACH 

ysis  has  occurred  previous  to  using  it  for  injection 
(Krida). 

If  the  patient's  serum  is  hemolytic  for  normal  cells,  an 
oval  area  of  discoloration  about  2  by  5  cm.  will  appear  at 
the  site  of  injection  in  from  5  to  8  hours. 

The  discoloration  is  described  as  ''brownish  red  to  a 
maroon,  wdth  rarely  a  bluish  tinge.  The  lesion  is  dis- 
tinctly raised  from  the  surrounding  surface."  The  dis- 
coloration persists  from  1  to  3  hours,  and  usuallj^  begins 
to  fade  at  the  end  of  8  hours,  lea"\dng  a  greenish  ecchymosis 
at  about  the  end  of  12  hours.  The  element  of  time  here  is 
variable,  however,  as  we  have  found.  If  the  patient  is  in  a 
hospital,  he  should  be  observed  about  once  an  hour,  begin- 
ning about  5  hours  after  the  injection,  and  making  3  or  4 
obser^^ations.  If  the  patient  be  at  home,  he  may  be  con- 
veniently seen  about  6  hours  after  the  injection.  If  the 
observation  then  made  be  inconclusive,  he  may  be  in- 
stmcted  to  notify  the  physician  should  a  reaction  appear 
within  3  or  4  hours. 

Elsberg,  Neuhoff  and  Geist  have  classified  the  results 
of  their  tests  as  follows : 

Carcinoma,  positive  or  probable,  69  cases,  62  or  89.9  per  cent,  plus  and 
2  or  2.9  per  cent,  doubtful. 

No  carcinoma,  325  cases,  15  or  4.6  per  cent,  plus  and  3  or  1.1  per  cent. 
doubtful. 

Possible  carcinoma,  9  cases,  7  or  77.8  per  cent.  plus. 

Carcinoma,  advanced  or  mOiary,  11  cases,  0  or  100  per  cent,  negative. 

Krida  states  that  of  12  cases  of  carcinoma,  the  reac- 
tion was  positive  in  9,  or  75  per  cent.  He  states  further 
that  the  reaction  is  not  uniformly  absent  in  the  cachectic 
cases.  Elsberg,  Neuhoff  and  Geist  have  made  such  a 
subdivision  and  found  the  results  negative  in  their  11  cases 
so  classified.     Warfield  thinks  the  test  of  dubious  worth. 


THE   BLOOD    IN    GASTRIC    CANCER  339 

It  is  certainly  interesting  from  a  biochemic,  and  perhaps 
anaphylactic  standpoint. 

Cancer  Diagnosis  of  Freund  and  Kaminer. — Miiller 
states  that  the  blood  serum  of  normal  individuals  some- 
times has  the  power  to  dissolve  cancer  cells.  The  blood 
serum  of  patients  suffering  from  cancer  frequently  lacks 
this  power,  and  has  the  power  to  inhibit  the  destruction  of 
such  cells  by  normal  serum. 

When  the  blood  serum  of  cancer  patients  is  mixed  with 
a  cancer  extract,  a  precipitate  forms. 

Ingredients  of  the  Test. — 1.  An  Emulsion  of  Cancer 
Cells. — Grind  in  a  mortar  the  necrotic  portions  of  the 
tumor,  freed  so  far  as  possible  of  fat  and  extraneous  cells, 
with  about  five  volumes  of  1  per  cent,  sodium  biphosphate. 
Squeeze  the  suspension  through  several  thicknesses  of 
gauze.  Allow  the  cells  to  settle,  and  remove  the  super- 
natant fluid  with  a  pipette.  Wash  the  residue  with  0.6 
per  cent,  sodium  chloride  solution.  Allow  the  cells  to 
settle  again,  pipette  off  the  supernatant  fluid  and  cover 
the  residue  with  1  per  cent,  sodium  fluoride.  The  last- 
named  fluid  should  be  first  neutralized  against  alizarin 
till  only  a  trace  of  violet  color  remains.  This  emulsion 
will  keep  for  several  weeks  in  the  ice-box. 

2.  An  Extract  of  Cancer  Cells. — Fresh  tumor  tissue 
obtained  at  autopsy,  or  tumor  tissue  preserved  in  alcohol 
may  be  used.  Portions  as  free  as  possible  of  necrotic 
areas  and  fat  are  cut  into  small  pieces  and  worked  through 
a  coarse-meshed  cloth  by  the  gradual  addition  of  ten 
volumes  of  0.6  per  cent,  acid  sodium  phosphate  solution. 
Allow  the  cells  to  separate  by  settling  or  by  careful  cen- 
trifugation.  Wash  several  times  with  the  same  fluid, 
and  preserve  at  0°.  Sodium  fluoride,  up  to  1  per  cent., 
may  be  added  as  a  preservative,  provided  care  is  taken 


340  CANCER    OF   THE    STOMACH 

to  see  that  it  does  not  render  the  fluid  alkahne.  Thymol 
may  also  be  used. 

For  use  add  5  cc.  of  5  per  cent  acetic  acid  to  100  cc. 
of  the  fluid.  Heat  the  mixture  in  the  water-bath  for  15 
minutes  at  80°  C,  filter,  cool,  and  neutralize  to  htmus  wdth 
sodium  carbonate .  Heat  again  as  above,  cool  and  filter. 
Heating  at  100°  C.  or  over  the  free  flame  must  be  avoided. 
The  activity  of  the  extract  is  determined  by  testing  with 
10  drops  of  known  normal  and  cancerous  sera  whether 
the  extract,  undiluted,  and  diluted  10,  50,  and  100  times, 
gives  a  precipitate  wdth  cancer  serum,  plainly  visible  in 
test-tubes  held  against  the  window,  while  the  normal 
serum  gives  no  such  precipitate.  The  extract  keeps  for 
only  2  or  3  days.  The  extract  if  used  in  too  concen- 
trated form  causes  a  precipitate  with  normal  serum,  but 
if  diluted  to  opalescence  gives  a  dismal  serum,  or  of  an 
ether  extract  of  horse  serum. 

3.  The  Patient's  Serum. — This  is  obtained  in  smy  of  the 
customary  ways.  The  serum  must  be  separated  from  the 
cells  Tvdthin  a  few  hours  after  the  blood  is  drawn  and  can- 
not be  used  when  it  is  more  than  48  hours  old. 

4.  A  hlood-counting  chamber. 

5.  Small  test-tubes  or  small  test  dishes  with  parallel 
sides. 

6.  Capillary  pipettes,  and  volumetric  pipettes,  1  cc.  in 
1-100's. 

7.  An  incubator  at  37°  C. 

8.  A  0.5  per  cent,  solution  of  sodium  fluoride. 
Technique. — To  10  drops  of  the  patient's  serum  add  1  drop 

of  the  0.5  per  cent,  solution  of  sodium  fluoride.  Then 
add  1  drop  of  the  cancer  cell  emulsion  so  diluted  that  when 
1  drop  of  the  mixture  is  placed  in  the  blood-counting 
chamber,  about  10  to  20  tumor  cells  will  be  found  in  a 


THE   BLOOD   IN    GASTRIC    CANCER  341 

large  field  (25  of  the  smallest  squares)  of  the  apparatus. 
Close  the  ct>unting  chamber  carefully  and  place  in  the 
incubator  for  24  hours.  Count  the  number  of  cells 
again. 

It  is  said  that  a  material  reduction  in  the  number  of 
cells  will  be  found  when  the  serum  is  derived  from  a  healthy 
individual,  whereas,  if  the  serum  is  derived  from  a  cancer 
patient  such  a  reduction  does  not  take  place. 

A  second  test  is  made  by  diluting  normal  serum  with 
an  equal  amount  of  0.6  per  cent,  sodium  chloride  solution, 
and  also  with  an  equal  volume  of  the  patient's  serum. 
To  each  of  these  fluoride  and  the  cell  emulsion  is  added 
as  above.  If  the  patient's  serum  prevents  the  solution  of 
the  cells  by  the  normal  serum,  this  again  constitutes  a 
positive  reaction. 

The  test  for  a  precipitate  is  made  as  follows:  Place  10 
drops  of  the  patient's  serum  in  a  small  test-tube  or  test 
dish  with  parallel  sides  and  add  2  cc.  of  the  extract  properly 
diluted  as  described  above.  Controls  are  made  by  add- 
ing to  a  separate  quantity  of  serum  a  fluid  identical  with 
the  tumor  extract  with  the  exception  of  the  tumor  tissue. 
In  other  words,  if  the  extract  was  prepared  from  fresh 
tumor  tissue  this  fluid  is  prepared  by  adding  to  100  cc. 
of  1  per  cent,  acid  sodium  phosphate  5  cc.  of  5  per  cent, 
acetic  acid,  and  neutralizing  with  sodium  carbonate. 
When  the  extract  is  prepared  from  tissues  preserved  in 
alcohol,  use  0.25  per  cent,  acetic  acid  neutralized  with 
sodium  carbonate. 

The  precipitate  forms  at  once  and  must  be  viewed  by 
transmitted,  not  by  reflected  light.  A  distinct  clouding 
under  these  conditions  constitutes  a  positive  reaction. 
Freund  and  Kaminer  recommend  that  all  three  tests 
should  be  made  when  enough  serum  is  available.     This 


342  CANCER  OF  THE  STOMACH 

calls  for  about  2.5  cc.  of  serum,  representing  about  6  cc. 
of  whole  blood  (Miiller- Whitman). 

The  Antitryptic  Reaction. — In  1902  Petry  demonstrated 
that  cancers  contain  a  proteolytic  ferment.  He  showed 
that  such  proteids  as  gelatin  or  casein  could  be  digested 
by  an  extract  of  the  malignant  tumor.  The  agent  causing 
this  digestion  appeared  to  have  the  properties  of  a  ferment. 
It  was  later  shown  that  the  passage  of  such  proteolytic 
ferments  into  the  circulation  resulted  in  the  formation  of 
anti-ferments  in  the  body  fluids,  especially  in  the  blood 
serum.  This  anti-ferment  was  named  ''antitrypsin."  It 
was  thought  that  a  method  of  measuring  the  strength  or 
the  amount  of  the  antitrypsin  would  indirectly  serve  as 
a  method  of  diagnosing  the  existence  of  malignancy,  inas- 
much as  it  had  been  demonstrated  that  normal  blood 
serum  contains  relatively  small  amounts  of  antitrypsin. 
In  1908,  Bergmann  and  Meyer  announced  a  method  whereby 
the  antitrypsin  content  of  blood  sera  could  be  estimated 
clinically.     Their  method  is  as  follows: 

Estimation  of  the  Antitrypsin  Content  of  the  Blood. — 
Principle:  One  determines  what  amount  of  trypsin  is 
neutralized,  as  to  its  digestive  power,  by  a  certain  amount 
of  serum  or  blood.  The  substance  to  be  digested  may  be 
either  Loeffler's  blood  serum,  as  ordinarily  used  by  bacteri- 
ologists, or  a  solution  of  casein.  In  the  former  case  the 
criterion  for  the  occurrence  of  digestion  is  the  formation 
of  a  dimple  on  the  surface  of  the  serum;  in  the  latter  the 
non-appearance  of  a  cloud,  due  to  the  precipitation  of 
casein,  on  the  addition  of  acetic  acid. 

Practical  Application. — Whitman  states  that  the  anti- 
trypsin of  the  blood  is  most  markedly  increased  in  cancer. 
Hence  the  method  has  been  used  chiefly  for  cancer 
diagnosis. 


THE   BLOOD    IN    GASTRIC    CANCER  343 

Method  of  Bergmann  and  Meyer.  -Apparatus. — 1.  A  1 
per  mille  solution  of  trypsin  sice.  (Gruebler) :  dissolve  0.5 
gram  trj^jsin  in  50  cc.  physiological  salt  solution,  add  0.5 
cc.  normal  soda  solution,  and  make  up  to  500  cc. 

2.  Casein  solution:  1  gram  casein  (rhenania)  is  dissolved 
in  100  cc.  n/10  NaOH  solution,  with  the  aid  of  gentle 
heat.  Neutralize  to  litmus  with  n/10  HCl  solution  and 
make  up  to  500  cc. 

3.  Acetic  acid  solution:  5  cc.  acetic  acid,  45  cc.  alcohol, 
and  50  cc.  water. 

4.  The  patient's  serum,  diluted  20  times  with  salt  solu- 
tion; 0.1  to  0.2  cc.  suffices. 

5.  Small  test-tubes. 

6.  Pipettes,  2  cc.  graduated  into  1-10's. 

Technique. — Titration  of  the  trypsin  solution.  This 
must  precede  the  test  proper.  In  each  of  several  test-tubes 
place  2  cc.  of  the  casein  solution  and  decreasing  amounts 
of  the  trypsin  solution  as,  for  example,  1.0,  0.9,  0.8,  0.7, — 
0.2.  Shake  carefully  and  place  in  the  incubator  for  }i  hour. 
Then  add  the  acetic  acid  solution  drop  by  drop,  observing 
which  tube  shows  cloudiness  after  a  few  minutes.  The  tube 
containing  the  smallest  amount  of  tr^^Dsin,  and  which 
remains  perfectly  clear,  contains  the  ^^  completely  digesting 
dose,"  which  is  used  for  the  test  proper. 

Estimation  of  the  Antitrypsin. — In  each  of  6  tubes  place 
0.2  cc.  of  the  patient's  serum,  and  increasing  amounts  of 
the  trypsin  solution,  beginning  with  the  completely 
digesting  dose,  and  increasing  by  0.1  cc.  xldd  2  cc.  casein 
solution  to  each  tube  and  bring  all  the  tubes  to  a  like 
volume.  Incubate  as  before  for  }4  tiour  at  37°  C.  Acidify 
as  before,  and  again  note  the  tube  containing  the  smallest 
amount  of  trypsin  in  which  cloudiness  can  be  seen.  The 
amount  of  trypsin  paralyzed  by  the  antitrj^psin  of  the 


344  CANCER  OF  THE  STOMACH 

serum  is  thus  determined.  If,  for  example,  the  completely 
digesting  dose  is  0.7  cc.  and  if,  in  the  presence  of  serum,  2.0 
cc.  of  trypsin  are  required  to  bring  about  complete  diges- 
tion, then: 

2.0  cc.  -  0.7  cc.  =  1.3  cc, 

or  the  amount  of  trypsin  paralyzed  by  the  amount  of  serum 
used  (in  this  case  0.2  cc.  of  a  5  per  cent,  dilution,  or  0.01 
cc.  whole  serum).  One  cc.  of  serum,  therefore,  paralyzes 
130  cc.  of  the  trypsin  solution.     Furst,  expresses  the  result 

as  follows: 

37°  C 
Antitrypsin  j;rr — -  =  130. 

Comparison  of  the  values  thus  obtained  with  those  given 
by  normal  serum  shows  whether  the  antitryptic  power  of 
the  serum  tested  is  altered  (Mtiller- Whitman) . 

The  method  of  Bergmann  and  Meyer  was  later  improved 
by  Weil  and  Feldstein,  by  the  introduction  of  the  '^viscos- 
imeter, "  an  instrument  permitting  accurate  determination 
of  the  end  point  of  digestion  of  a  pure  proteid  by  blood 
serum. 

From  the  perusal  of  a  huge  literature,  it  would  appear 
that  the  ''antitryptic  reaction"  in  the  blood  serum  is 
positive  in  from  75  to  95  per  cent,  of  all  cancers.  It  is  of 
comparative  rarity  in  the  blood  serum  of  non-cancerous 
patients.  That  it  has  a  definite  place  as  an  aid  in  differen- 
tial diagnosis  is  attested  by  Stockton,  Bergmann  and  Meyer, 
Roche  and  others. 

Roche  emphasizes  the  great  importance  of  negative  anti- 
tryptic reactions  in  excluding  the  diagnosis  of  malignancy. 

Abderhalden  Method  for  the  Detection  of  Specific 
Ereptases. — Numerous  investigators  have  demonstrated 
the  presence  of  ereptic  ferments  in  blood  serum.  It 
remained  for  Abderhalden,  however,  to  show  that  specific 


THE   BLOOD   IN    GASTRIC    CANCER  345 

ereptases  were  developed  or  increased  by  the  presence  of 
a  foreign  proteid  (parenterally)  or  by  the  growth  of  neo- 
plasms in  the  body.  The  protective  mechanism  of  the 
organism  appears  to  take  the  form  of  a  highly  specialized 
ereptic  ferment  capable  only  of  digesting  the  proteid  com- 
posing the  type  of  tumor  exciting  its  production. 

Principle. — The  blood  serum  of  cancer  individuals  con- 
tains a  specific  ferment  which  digests  cancer  cells. 

Apparatus. — 1.  Cancer  tissue.- — Cut  a  fresh  human  cancer 
into  small  pieces,  place  in  a  wide  dish,  and  wash  in  running 
(tap)  water.  The  external  portions  may  be  separated  and 
discarded,  but  this  is  not  necessary.  While  the  washing, 
which  is  for  the  purpose  of  removing  blood,  is  going  on,  a 
large  enamel  basin  or  evaporating  dish  containing  1  to  2 
liters  of  water,  to  which  1  drop  per  liter  of  glacial  acetic 
acid  is  added,  is  heated  to  boiling.  Throw  the  washed 
cancer  tissue  into  the  boiling  water,  and  continue  the 
boiling  for  5  minutes.  Pour  off  the  boiling  water  through  a 
gauze  strainer  or  plaited  filter,  taking  care  that  the  coagu- 
lated bits  of  cancer  remain  as  far  as  possible  in  the  dish. 
Pour  on  more  water  and  boil  again  for  5  minutes.  Now 
test  a  portion  of  the  water  for  the  biuret  reaction  as  follows : 
To  about  10  cc.  of  the  water,  add  5  cc.  of  a  33  per  cent, 
caustic  soda  solution,  mix  and  layer  enough  of  a  very  dilute 
(0.25  per  cent.)  solution  of  cupric  sulphate  on  top  to  make 
a  layer  0.25-0.5  cm.  deep.  A  red  color  at  the  zone  of  con- 
tact constitutes  a  positive  reaction.  If  the  process  has 
been  carried  out  rapidly,  the  test  will  always  be  negative. 

In  place  of  the  biuret  reaction  for  peptone  the  more  deli- 
cate triketohydrinden  hydrate  (Hoechst),  may  be  used. 
This  gives  a  blue  color  with  compounds  which  have  a  COOH 
group  and  an  amino-acid  in  the  ''a"  position.  Albumin, 
peptone,  polypeptids  and  amino-acids  react.     Place  10  cc. 


346  CANCER   OF   THE    STOMACH 

of  the  fluid  in  a  large  test-tube,  add  exactly  0.2  cc.  of  a  1 
per  cent,  aqueous  solution  of  triketohydrinden  hydrate, 
bring  quickly  to  boiling  and  continue  the  boiling  for  1 
minute  without  interruption.  When  the  reaction  is  posi- 
tive, a  beautiful  violet-blue  color  develops  in  a  short  time. 
When  negative,  the  solution  remains  colorless,  or  takes  on  a 
yellowish  tone.  The  use  of  the  triketohydrinden  hydrate 
is  recommended,  but  it  must  not  be  used  for  the  test  proper 
unless  the  cancer  tissue,  as  prepared  above,  has  been  shown 
to  react  negatively  with  it. 

If  the  water  in  which  the  cancer  is  cooked  gives  one  or 
other  of  these  reactions  for  peptone,  the  boiling  must  be 
continued  as  before  till  the  reaction  is  negative.  When 
this  occurs  pour  the  last  cooking  water,  together  with  the 
cancer  tissue,  into  a  wide-mouthed  flask.  Cover  with  a 
layer  of  toluol,  and  cork  tightly.  The  entire  process 
requires  not  more  than  3^  to  1  hour,  and  furnishes  material 
for  several  hundred  tests. 

2.  Extraction  thimbles.  (S.  and  S.  579.)  These  should 
be  kept  under  water  and  a  layer  of  toluol,  and  should  be 
tested  for  permeabihty  to  Witte's  peptone  before  use. 
After  being  used,  they  may  be  carefully  washed  in  running 
water  and  used  again.     They  should  never  be  used  dry. 

3.  The  patient's  serum.  This  must  not  be  shaken.  It  is 
recommended  to  allow  about  10  cc.  of  blood  to  flow  directly 
into  a  centrifugal  tube.  As  soon  as  the  clot  forms  cen- 
trifugate,  pour  off  the  serum,  and  use  at  once  for  the 
test.  If  the  serum  contains  any  hemoglobin  it  cannot  be 
used. 

4.  Small  heakers,  Erlenmeyer  flasks  or  especially  designed 
cyHnders  of  such  a  size  that  the  thimbles  above  mentioned 
fit  into  them  leaving  not  more  than  0.25  cm.  between  the 
shell  and  the  wall. 


THE    BLOOD    IX    GASTRIC    CANCER  347 

5.  Reagents  for  the  biui'et  reaction,  or  triketohydrinden 
hydrate,  or  both. 

6.  Incubator  at  37°  C. 

7.  Distilled  water. 

Technique. — In  one  of  the  extraction  thimbles,  pre- 
viously tested  as  to  its  pemieabihty,  washed,  and  kept  as 
above  described,  place  about  1  gram  of  the  cancer  tissue, 
crumbling  it  between  the  fingers  into  pieces  the  size  of  a 
wheat  grain  while  doing  so.  Pour  about  2  or  3  cc.  of  the 
patient's  serum  over  the  tissue  in  the  bottom  of  the 
thimble.  Add  a  few  drops  of  the  toluol  to  prevent  putre- 
faction. Xow  hold  the  thimble  at  the  top,  and  rinse  the 
outside  thoroughly  under  the  tap.  Place  the  thimble  in  one 
of  the  beakers,  described  above,  and  add  15  cc.  of  water, 
outside  the  thimble.  A  thin  layer  of  toluol  is  placed  also 
on  the  outside.  Controls  should  be  prepared  in  the  same 
wa3',  consisting  of  the  patient's  serum  alone,  and  of  the 
cancer  tissue  alone,  respectively.  Place  in  the  incubator 
for  12-16  hours.  Xow  remove  10  cc.  of  the  fluid  outside 
of  the  thimble,  by  means  of  a  pipette,  thrust  below  the  level 
of  the  toluol,  and  test  this  for  peptone  with  one  or  both  of  the 
reagents  described  above.  When  triketohydrinden  hy- 
drate is  to  be  used,  it  is  especially  important  that  as  httle 
toluol  as  possible  be  transferred  to  the  test-tube,  as  over- 
heating is  then  apt  to  occur.  A  glass  rod  may  be  placed 
in  the  test-tube  to  prevent  bumping. 

A  positive  result  is  indicated  when  the  dialysate  gives 
a  positive  reaction  for  peptone. 

The  method  has  been  verified  by  R.  Franz  and  by  Frank 
and  Heimann. 

The  polariscope  method  of  Abderhalden  is  sometimes 
used.  It  is  too  compHcated  for  general  clinical  applica- 
tion (Aliiller- Whitman) . 


348  CANCER  OF  THE  STOMACH 

Ransohoff's  Anaphylaxis  Test  for  Cancer. — Guinea-pigs 
are  sensitized  by  the  intraperitoneal  injection  of  blood- 
serum  from  (a)  a  normal  patient  and  (5)  a  patient  affected 
with  advanced  cancer.  At  the  end  of  10  days,  each  group 
of  guinea-pigs  is  injected  with  known  malignant  serum, 
intraperitoneally.  When  such  serum  is  introduced  into 
guinea-pigs  sensitized  with  cancer  serum,  typical  anaphy- 
lactic reactions  are  claimed  to  develop.  The  injection  of 
serum  into  guinea-pigs  into  whom  non-cancer  serum  had 
been  previously  introduced  causes  very  slight  local  or 
systemic  disturbance  or  none  at  all. 

Ransohoff  states  that  in  his  hands  the  test  proved  posi- 
tive for  92  per  cent,  of  26  cancer  cases  tested. 

The  Miostagmin  Reaction. — Ascoli  and  his  pupils 
have  presented  a  blood-serum  reaction  based  upon  certain 
principles  of  physical  chemistry.  They  claim  that  when 
the  essential  principles  of  a  specific  antigen  are  extracted, 
the  resultant  extract,  if  added  to  a  suspected  blood  serum, 
produces  such  alteration  that  variations  in  surface  tension 
may  be  measured.  These  alterations  are  estimated  by 
a  Traube  stalagmometer  before  and  after  incubation  of 
the  antigen-extract-serum  mixture.  Ascoli  claims  that 
such  changes  in  surface  tension  occur  when  antigen  and 
specific  antibody  unite,  that  the  decrease  in  surface  ten- 
sion may  result  in  stalagmometric  readings  showing  an 
increase  of  from  2  to  5  drops. 

The  Ascoli  reaction  is  very  complicated.  While  in  its 
originator's  hands  it  seems  to  be  a  valuable  aid  in  the 
diagnosis  of  cancer,  numerous  competent  investigators 
(Kelling,  Bernstein  and  Simons  and  others)  claim  that  the 
reaction  has  little  clinical  worth. 


THE  BLOOD  IN  GASTRIC  CANCER  349 

REFERENCES 

Cabot:  "A  Guide  to  the  Clinical  Examination  of  Blood,"  New  York, 

1904. 
OsLER  AND  McCrae:  "Cancer  of  the  Stomach,"  Philadelphia,   1900. 
Cunliffe:  Medical  Chronicle,  Sept..  1903. 
Bonhoff:  Beitr.  z.  klin.  Chir.,  Tubingen,  1914,  June,  xcii. 
Lang:  Ztschrft.  f.  klin.  Med.,  1902,  xiii,  p.  106. 
Weil,  R.:   Arch.  Int.  Med.,  1908,  i,  p.  28. 
Krida:  Albany  Medical  Annals,  1910,  May,  p.  259. 
Elsberg,  Neuhoff  and  Geist:  Am.  Jour.  Med.  Sc,  1910,  Feb.,  p.  264. 
Warfield:  Arch.  Int.  Med.,  1911,  Nov.,  p.  621. 
Muller:  "Serodiagnostic  Methods,"  1913,  Philadelphia  and  London. 

Translated  by  R.  C.  Whitman. 
Freund    &    Kaminer:  Biochem.    Ztschrft.,    1910;   also  Wien.    klin. 

Wchnrft.,  1910,  xiii.,  pp.  378  and  1221,  and  1911,  xxiv.,  p.  1759. 
Bergmann  and  Meyer:  Berl.  klin.  Wschnschrft.,  1908,  xiv,  p.  1673. 
Weil,  R.  and  Feldstein:  Proc.  Soc.  Exper.  Biol,  and  Med.,  1910,  vii, 

p.  61. 
Stockton:  "Diseases  of  the  Stomach,"  New  York,  1914. 
Roche:  Arch.  Int.  Med.,  1909,  April,  p.  1. 
Abderhalden:  "Schutzfermente   des  tierischen    Organismus,"  Berlin, 

1912;  also  Miinch.med.  Wchnrft.,  1912,  Ux.,  pp.  1305, 1939  and 2172. 
Franz:  Miinch.  med.  Wschnschrft.,  1912,  hx.,  p.  1702. 
Frank  and  Heimann:   Berl.  klin.  Wschnschrft.,  1912,  lix,  p.  1706. 
Ransohoff,  Jour.  Am.  Med.  Assn.,  1913,  July  5,  p.  8. 
AscOLi:  Miinch.  med.  Wschnschrft.,  1910,  Jan.  11,  p.  63. 
AscoLi  AND  Izar:  Ihid.,  1910,  Feb.  22,  p.  403. 
AscoLi:  Ihid.,  1910,  Oct.  11,  p.  2129. 

Ascoli:  Deutsch  med.  Wschnschrft.,  1910,  Oct.  27,  p.  1997. 
Kelling:  Wien  klin.  Wschschrft.,  1911,  Jan.,  No.  3. 
Bernstein  and  Simons:  Am.  Jour.  Med.  Sc,  1911,  Dec. 


\'-- 


CHAPTER  VIII 

THE  SIGNIFICANCE  OF  GASTRIC  ULCER  WITH 
RESPECT  TO  GASTRIC   CANCER 

During  the  past  decade  there  has  been  a  growing  con- 
viction among  clinical  and  laboratory  workers  that  there 
exists  an  increasing  number  of  cases  clinically  admitting  a 
diagnosis  only  of  chronic  gastric  ulcer  which  do  not  pur- 
sue an  orthodox  course  of  chronicity,  but  often  rapidly 
assume  aspects  of  malignant  disease.  If  such  cases  come 
to  laparotomy  or  necropsy,  the  surgeon  or  pathologist 
demonstrates  cancer. 

Conversely,  surgically  and  pathologically  proved  cases 
of  gastric  cancer  frequently  reveal  an  early  clinical  history, 
which  at  any  stage  prior  to  the  terminal  period  of  evident 
malignancy  might  logically  be  interpreted  clinically  as 
chronic  gastric  ulcer. 

The  subject  has  etiologic,  diagnostic  and  prognostic 
aspects.  Inasmuch  as  this  group  of  cases  satisfies  our 
present  day  diagnostic  requirements  for  gastric  ulcer  and 
this  process,  of  whatever  nature  it  may  be,  later  assumes 
characteristics  that  we  associate  with  malignancy,  it 
would  appear  imperative  to  determine  how  frequently 
this  type  of  affection  exists,  in  what  manner,  if  any,  it 
manifests  itself,  the  possibilities  of  its  recognition  and  the 
indicated  treatment  when  demonstrated. 

At  the  present  state  of  our  knowledge  it  is  impossible 
to  prove  how  frequently  gastric  ulcers  become  cancers. 
Whatever  individual  opinion  may  be,  this  statement  holds 
true.  There  are  many  reasons  why  conclusive  facts 
cannot  yet  be  given.     Some  of  these  we  would  emphasize: 

350 


THE    SIGNIFICANCE    OF   GASTRIC    ULCER  351 

(a)  Regional  variation  in  the  incidence  of  gastric  ulcer. 
In  1864  Brinton  claimed  that  peptic  ulcer  was  found  at 
necropsy  in  from  2  to  13  per  cent,  of  persons  dying  from 
all  causes.  The  average  incidence  was  approximately 
5  per  cent.  These  figures  have  been  much  quoted  and 
indiscriminately  compared.  It  will  be  recalled  that 
they  were  collected  at  a  time  when  pathological 
methods  were  poorly  developed.  Modern  writers  have 
shown  that  not  only  is  there  a  wide  range  in  incidence  of 
peptic  ulcer  in  different  countries,  but  that  there  is  also 
striking  variation  in  its  occurrence  in  different  parts  of 
the  same  country.  In  a  recent  and  careful  survey  of  the 
subject  Bolton  points  out  that  pathological  statistics 
collected  from  Europe  and  America  indicate  that  this 
variation  ranges  between  0.5  per  cent,  and  20  per  cent. 
Bolton  gives  the  average  figures  as  follows:  Denmark 
16.7  per  cent.,  England  5  per  cent.,  Germany  5  per  cent., 
Austria  4  per  cent.,  Switzerland  2.6  per  cent.,  North 
America  1.3  per  cent.,  Russia  0.8  per  cent.  It  is  said  that 
in  North  Germany  the  disease  is  about  as  frequent  as  it  is 
in  Denmark,  while  parts  of  South  Germany  approximate 
the'  average  for  North  America.  Whatever  may  be  the 
estimated  incidence  based  upon  clinical  diagnoses,  post- 
mortem, or  laparotomy  statistics  are  the  only  figures  upon 
which  we  can  base  dependable  comparisons.  We  have 
already  shown  (Chapter  I)  that  our  921  instances  of 
operatively  and  pathologically  demonstrated  cases  of  gastric 
cancer  occurred  in  about  82,000  hospital  admissions. 
This  indicates  an  incidence  of  1.12  per  cent.  In  ap- 
proximately the  same  number  of  admissions  there  were 
operatively  demonstrated  1250  chronic  or  acute  gastric 
ulcers,  or  a  percentage  of  1.51.  It  is  seen  that  the 
incidence  of  proved  gastric  cancer   and   gastric   ulcer  in 


352  CA^XER  OF  the  stoimach 

our  hospital  admissions  did  not  vary  greatly.  Compar- 
ing the  two  percentages,  it  is  remarkable  to  note  that  the 
cancer  incidence  is  approximately  74  per  cent,  of  that  of 
gastric  ulcer.  TSTien  the  appended  analj'sis  of  the  rela- 
tion of  ulcer  and  cancer  is  considered,  it  must  be  admitted 
that  this  figm^e  is  striking.  The  above  is  an  American 
experience  and,  hence,  scarcely  comparable  with  that 
in  other  countries.  ^Moreover,  it  is  an  experience  largely 
from  the  Central  and  Xorthwest  United  States  and 
Southern  Canada. 

(b)  Variation  in  pathologic  opinion  as  to  the  life  history 
of  gastric  ulcer  and  of  gastric  cancer.  While  the  literature 
contains  many  excellent  monographs  descriptive  of  gastric 
ulcer,  the  researches  of  Bolton  supply  us  with  practically 
our  only  dependable  evidence  of  such  elementarj^  knowl- 
edge as  that  an  acute  gastric  ulcer  ma^^  progi^ess  to  chron- 
icity  and  is  not  a  different  clinical  entity.  Bolton's  inves- 
tigations appear  to  be  warranted  by  both  histologic  and 
clinical  facts.  This  observer  has  not  yet  demonstrated  car- 
cinomatous changes  in  any  of  his  chronic  gastric  ulcers. 
Certainly  if  some  of  the  photomicrographs  submitted  were 
examined  by  oil-immersion  lens,  it  would  be  rather  difficult 
to  exclude  the  presence  of  h^-perplasia  approaching  the 
malignant  form  described  by  IMacCarty. 

With  respect  to  the  histologic  demonstration  of  the 
beginnings  of  so-called  ''primary'"  gastric  cancer,  we  are 
more  uncertain  than  with  respect  to  known  cell  change  in 
gastric  ulcer.  Xo  one  has  ever  seen  the  actual  transition  of 
ga-stric  mucosa  from  benignness  to  maUgnancy.  One  can 
only  say  of  a  given  specimen  that  cancer  is  present  or  it  is 
absent.  It  would  appear,  however,  that  careful  study  of 
fresh  tissue  with  highest  magnification  reveals  certain 
undifferentiated    cells   which    aid   in   the   segregation    of 


THE    SIGNIFICANCE    OF   GASTEIC   ULCER  353 

benign  from  malignant  hyperplasia  (MacCarty).  When 
such  is  present  a  "precancerous"  state  not  infrequently 
seems  to  exist  (vide  infra). 

(c)  The  variation  in  an  accepted  clinical  complex  of 
gastric  ulcer.  We  refer  in  full  to  this  below.  Modern 
investigations  would  certainly  warrant  the  statement  that 
the  chnical  diagnosis  of  gastric  ulcer  is  by  no  means  simple 
and  according  to  well-marked  symptoms  and  signs.  It  is 
now  generally  admitted  by  those  who  have  followed  the 
progress  of  any  considerable  group  of  cases  that  many  of 
the  instances  which  were  formerly  classed  as  gastiic  ulcer 
are  not  such,  but  are  gastric  evidences  of  extragastric 
disease.  This  appUes  especially  to  cases  below  age  30,  who 
present  many  of  our  so-called  ulcer  symptoms,  clinically. 

(d)  The  tendency  to  cloud  our  present-day  knowledge 
with  ancient  statistics  and  imperfect  pathologic  and  histologic 
descriptions.  To  those  famiUar  with  the  hterature,  it  is 
not  necessary  to  point  out  the  hindrances  to  the  advance  of 
knowledge  that  have  resulted  from  the  constant  quoting 
of  work  done  by  investigators  of  a  half  century  ago. 
Such  researches  were  remarkably  acute  for  their  day,  but 
modern  science  would  indeed  have  cause  for  regret  if  it 
were  not  able  to  claim  new  facts  with  its  added  arma- 
mentarium for  research.  The  developments  of  laboratory 
methods  for  the  preservation  and  study  of  tissue,  the  im- 
provement in  microscopes,  the  checking  up  of  clinical 
material  pathologically,  the  advance  in  hospital  facilities 
for  examination  of  disease,  and  the  systematization  and 
standardization  of  records,  have  all  contributed  toward 
rendering  extremely  questionable  the  points  upon  which 
classifications  of  gastric  ulcer  and  cancer  were  made  20  to 
70  years  ago.  Except  for  the  historical  interest,  one  would 
hardly  think  of  burdening  himself  with  the  pathology,  his- 

23 


354  CANCER   OF   THE    STOMACH 

tology  and  bacteriology  of  syphilis,  meningitis,  malaria  or 
typhoid  fever  as  set  down  three  decades  ago,  yet  strenuous 
attempts  are  still  made  to  fit  twentieth  century  gastric  ulcer 
and  gastric  cancer  to  the  conception  of  it  a  half  century  ago. 
It  is  quite  possible  that  these  diseases  have  altered  in  many 
ways  as  succeeding  generations  have  harbored  them,  or 
that  environment  has  had  such  effect.  That  variations  are 
within  the  range  of  probability  is  evidenced  by  a  study 
of  the  clinical  history  of  syphilis,  leprosy,  typhus  fever, 
poliomyelitis,  gout,  etc. 

For  the  purpose  of  returning  facts  regarding  the  relation- 
ship between  gastric  cancer  and  gastric  ulcer,  the  author 
recently  made  an  analysis  of  566  operatively  and  patho- 
logically demonstrated  cases  of  gastric  cancer. 

CLINICAL  CONSIDERATION 

Significance  of  History. — Sex. — In  the  566  cases  there 
were  436  males,  and  130  females,  or  3.1  males  to  each 
female.  We  have  shown  that  this  is  very  near  the  sex 
ratio  existing  in  non-malignant,  chronic  gastric  ulcer. 

Age. — The  youngest  patient  in  the  series  was  20  years 
of  age;  there  were  26  patients  aged  over  70.  More  than 
three-fourths  of  the  cases  came  between  the  ages  of  40  and 
70  years.  A  comparative  study  of  134  .cases  of  non- 
malignant  chronic  gastric  ulcers  shows  that  rather  more 
than  one-half  were  in  the  40-  to  70-year  period. 

Etiologic  Factors. — A  history  of  trauma  was  obtained 
in  3.4  per  cent,  of  the  cases.  In  2.9  per  cent,  the  trau- 
matism occurred  in  the  early  history  of  the  affection,  and 
frequently  appeared  to  cause  or  precipitate  symptoms. 
There  were  three  instances  in  which  husband  and  wife 
became  affected  with  cancer  within  a  few  months  of  each 
other.     A  family  or  blood-relationship  history  was  obtain- 


THE    SIGXIFICAXCE    OF    GASTRIC    ULCER  355 

able  in  9.2  per  cent.;  and  a  history  of  tuberculosis  in  1.2 
per  cent. 

Previous  Disorders  of  Digestion  (the  "Precancerous 
History). — INIore  than  10  years  ago  Graham  called  attention 
to  the  significance  of  the  eailj  clinical  history  in  patients 
presenting  themselves  in  his  ser^dce  for  evident  gastric 
cancer.  He  stated  that  more  than  47  per  cent,  of  his 
operatively  demonstrated  cases  of  cancer  had  had  previous 
histories  which  strongly  suggested  that  the  cancer  had 
followed  a  chronic  gastric  ulcer,  existing  variouslj^  from 
3  to  37  years.  Graham  also  emphasized  the  fact  that 
nearly  40  per  cent,  of  his  cases  of  cancer  were  not  asso- 
ciated with  the  pre^dous  so-called  ''ulcer  history,"  but 
that  in  this  group  of  cases  cancer  developed  in  stomachs 
which  formerly  functionated  normally. 

The  value  of  early  history  as  indicating  that  succeeding 
cancer  of  the  stomach  has  its  origin  in  such  hypothetic 
ulcer  has  been  justly  questioned.  The  weakness  of  the 
argument  appears  to  be  at  least  threefold:  [1)  the  clinical 
variation  in  an  ulcer  symptom-complex,  (2)  the  indefinite 
ideas  existing  as  to  the  time  element  in  the  development  of 
"chronic''  ulcer  and  of  cancer,  and  (3)  the  difficulties  in 
actually  proving  whether  or  not  a  process  ichich  is  later 
shown  to  he  malignant  ivas  ever  anything  else.  I  shall 
consider  these  points  seriatim. 

1.  To  admit  the  indefiniteness  of  an  ulcer  symptom- 
complex  is  to  grant  at  once  that  mistakes  in  diagnosis  are 
readily  possible.  That  this  is  a  fact  has  come  within  the 
experience  of  all  gastrologists  who  have  handled  either  a 
few  or  a  large  number  of  cases.  In  spite  of  personal 
opinions,  we  must  admit  that  the  only  gastric  ulcers  that 
we  can  positiveh^  say  exist  are  those  whicli  we  can  see  or 
feel.     AATiile  it  ma}'  be  clinically  safer  to  treat  a  given 


356  CANCER  OF  THE  STOMACH 

case  as  gastric  ulcer,  as  recommended  by  Shutz,  never- 
theless such  uncertain  procedures  have  undoubtedly  led 
to  error,  confusion  and  injury  to  patients.  The  prognostic 
aspect  of  the  case  is  of  greater  import  than  the  question 
of  type  of  treatment  based  on  uncertain  diagnosis. 

In  endeavoring  to  gauge  the  importance  of  the  previous 
(the  precancerous)  gastric  history  of  the  cases  in  our 
series  we  found  it  necessary  to  group  them  according  to 
accepted  clinical  symptom-complexes,  of  ulcer  and  of 
cancer,  respectively.  This  mode  of  procedure  has  many 
faults,  but  it  should  be  emphasized  that  this  method  of 
classification  furnishes  the  bulk  of  the  literature  on  the 
subject. 

The  clinical  symptom-complex  considered  for  gastric 
ulcer  is  based  on  Friedenwald's  recently  analyzed  409 
cases,  while  that  for  cancer  is  compiled  from  the  work  of 
Osier  and  McCrae.  If  the  value  of  such  grouping  is 
questioned,  then  the  value  of  much  that  makes  up  accepted 
clinical  knowledge  of  the  diagnosis  and  the  treatment  of 
the  two  ailments  must  also  be  questioned.  If  the  symptom- 
complexes  indicated  mean  clinically  ulcer  or  cancer  of 
the  stomach,  then  the  facts  that  we  have  to  present  are 
not  without  significance. 

We  have  taken  the  following  symptom-complex  to  mean 
gastric  ulcer  clinically:  a  form  of  gastric  malfunction 
occurring  usually  between  the  ages  10  and  70  years,  char- 
acterized by  periodic  or  continuous  abdominal  discomfort 
or  pain,  frequently  bearing  definite  relation  to  food  inges- 
tion, and  often  associated  with  epigastric  or  dorsal  tender- 
ness, vomiting,  loss  of  blood  (hematemesis  or  melena)  and 
with  hyperacid  gastric  contents. 

We  have  considered  as  '^ primary  ^^  cancer,  clinically  a 
form  of  gastric  malfunction  of  a  downwardly  progressive 


THE    SIGNIFICANCE    OF    GASTRIC    ULCER  357 

nature,  usually  occurring  in  persons  between  the  ages  of  40 
and  70  years,  who  have  been  previously  normal  gastrically, 
the  imperfect  function  being  characterized  by  abdominal 
distress  or  pain,  usually  associated  with  cachexia,  loss  of 
blood,  epigastric  tumor,  vomiting  and  with  gastric  contents 
revealing  motor  defects,  low  free  hydrochloric  acid  and  the 
presence  of  organic  acids  and  of  foreign  microorganisms. 

In  grouping  our  material  under  these  accepted  clinical 
symptom-complexes,  we  find  that  of  the  566  proved  cases 
of  gastric  cancer,  239  or  41.8  per  cent,  fall  into  the  cancer- 
following-ulcer  classification,  while  182  or  32.1  per  cent,  are 
in  the  ^'primary"  cancer  division.     There  is,  in  addition,  a 
group  which  may  be  termed  cases  of  ''irregular  ulcer"  that 
numbers  106,  or  18.7  per  cent.     Twenty-two  patients  (3.9 
per  cent.)  had  a  previous  chnical  history  of  gall-bladder 
affection,  while  17  or  3  per  cent,  had  early  symptoms  point- 
ing to  primary  processes  in  the  appendix,  the  pancreas  or 
the  bowel.     Combining  the  returns  from  the  two  "ulcer" 
groups,  it  is  seen  that  precancerous  history  indicates  that 
60.5  per  cent,  of  the  subsequently  demonstrated  cases  of 
cancer  gave  those  cUnical  evidences  which  we  associate 
with  chronic  gastric  ulcer,  prior  to  the  time  when  the  ail- 
ment assumed  the  cUnical  picture  that  we  associate  with 
gastric  malignancy.     In  but  32.1  per  cent,  was  the  disease, 
from  its  inception,  continuous  and  progressively  downward, 
and  in  persons  who  had  been  previously  sound  gastric- 
ally.     These  figures  are  not  to  be  taken  as  they  stand  to- 
indicate    that    nearly    two-thirds    of    all    chronic    gastric 
ulcers   later  become   malignant,   because   we   know   that 
ulcers  frequently  heal  spontaneously  or  continue  as  chronic, 
inflammatory  processes.     Added  significance,  however,  is 
given  to  the  figures  by  the  observation  of  the  surgical 
pathologist  that  more  than  two-thirds  of  all  excised  chronic 


358  CANCER   OF   THE    STOMACH 

calloused  gastric  ulcers  show  early  evidences  of  malignant 
metamorphosis  (Wilson  and  MacCarty). 

2.  The  analysis  of  any  considerable  material,  ulcer  or 
cancer,  reveals  many  striking  variations  in  the  duration  of 
the  morbid  process.  Both  clinical  and  pathologic  differen- 
tiation should  be  made  between  the  terms  "old"  and 
"chronic"  as  applied  to  ulcer  and  cancer.  Chronicity, 
pathologically,  does  not  necessarily  mean  that  the  disease 
is  old,  that  is,  of  long  duration  in  terms  of  months  or  years. 
Large,  excavated,  calloused  ulcers  may  apparently  develop 
in  a  few  weeks,  while  many  small,  indurated  round  ulcers 
may  give  even  obstructive  symptoms  for  years.  This 
also  applies  to  cancer.  Within  2  weeks  of  the  onset  of 
disabihty  we  have  seen  a  patient  exhibit  general  carcinosis, 
with  a  large  primary  mass  in  the  stomach.  Another  patient 
may  have  noticed  an  epigastric  nodule  for  a  year,  and  yet 
laparotomy  demonstrates  a  small  mass  well  confined  to  the 
wall  of  the  stomach. 

The  average  length  of  time  of  all  symptoms  in  our  182 
cases  clinically  satisfying  the  symptom-complex  of  cancer 
was  7.1  months.  Of  this  group  the  shortest  history  ex- 
tended over  but  2  weeks,  and  the  longest  was  about  3  years. 
In  9  cases  (1.6  per  cent.)  cancer  of  the  stomach  was  found 
at  exploration,  when  there  had  been  no  indications  of  gastric 
disorder.  Such  cases  have  been  described  by  Osier, 
Chesnel  and  others. 

Of  the  239  cases  clinically  furnishing  the  symptom- 
complex  of  a  chronic  gastric  disorder  previous  to  the  period 
of  evident  malignancy,  the  average  duration  of  all  symp- 
toms was  11.4  years.  In  this  group  the  average  duration 
of  the  supervening  malignant  course  was  6.1  months.  It 
seems  thus  manifest  that  the  periods  of  downward  progression 
closely  approximate  in  the  two  classes  of  cases,  wholly  inde- 


THE    SIGNIFICANCE    OF   GASTRIC   ULCER  359 

pendent  of  the  earlier  gastric  history  of  the  case.  From 
our  knowledge  of  malignant  processes  in  general,  it  would 
seem  scarcely  possible  that  the  "primary"  cases  of  cancer, 
mentioned  before,  existed  for  any  considerable  length  of 
time  without  giving  cUnical  evidences  of  their  presence. 
Especially  is  this  emphasized  when  we  are  aware  that  be- 
tween 60  and  70  per  cent,  of  all  proved  cases  of  chronic 
gastric  ulcer  and  of  gastric  cancer  are  so  located  in  the 
visceral  wall  as  to  early  interfere  with  the  stomach's 
emptying  power.  We  have  been  frequently  impressed  by 
the  fact  that  many  so-called  ''primary"  gastric  cancers  in 
the  early  weeks  of  their  disturbance  gave  such  cHnical 
symptoms  as  are  commonly  ascribed,  cUnically,  to  chronic 
ulcer. 

3.  The  demonstration  that  a  long-standing  gastric 
disturbance  which  is  later  shown  to  be  malignant  was  ever 
benign  leads  largely  into  realms  of  speculation.  The 
chief  arguments  in  support  of  this  supposition  appear  to 
be  the  following: 

(a)  After  gastro-enterostomy  for  chronic  ulcer,  when 
the  ulcer  is  not  excised,  it  is  stated  that  such  patient 
rarely  develops  gastric  cancer  (Paterson,  Gressot  and 
others).  The  argument  loses  much  of  its  force  when  we 
recall  that  in  such  subject  the  entire  physiology  of  the 
stomach  and  related  viscera  may  have  been  upset.  It  is 
well  recognized  by  able  surgeons  and  phj^siologists  that 
gastro-enterostomy  is  more  than  a  simple  procedure  of 
''drainage."  In  the  large  majority  of  gastric  extracts  from 
stomachs  where  gastro-enterostomy  has  been  performed, 
it  is  possible  to  demonstrate,  chemically  or  microscopic- 
ally, both  duodenal  and  jejunal  contents.  Just  what  effect 
these  foreign  substances  have  on  gastric  ulcers  or  gastric  can- 
cers we  have  yet  no  means  of  knowing.     We  do  know,  how- 


360  CANCER  OF  THE  STOMACH 

ever,  that  the  parts  of  the  aUmentary  tract  from  which  they 
come  are  rarely  affected  with  cancer.  In  our  series  of  cases 
of  gastric  cancers,  there  are  four  patients  which  later  devel- 
oped cancer  following  gastro-enterostomy  for  ulcer.  It 
also  seems  to  hold  that  in  cases  of  gastric  cancer  in  which  no 
pyloric  obstructions  are  demonstrable  gastro-enterostomy 
grants  a  longer  lease  of  life  than  when  such  operations  have 
not  been  performed.  After  gastro-enterostomy,  stomach 
emptying  is  more  rapid  than  before.  This  freeing  the 
viscus  of  irritant  food  and  secretions,  and  the  cast-off 
material  from  ulcers  or  cancers,  might  be  a  not  incon- 
siderable factor  in  the  after  course,  histologically,  of  such 
lesions. 

(6)  Duodenal  ulcer  of  the  indurated  type  is  a  relatively 
more  common  affection  than  is  gastric  ulcer,  yet  carcinoma 
of  the  duodenum  is  a  rarity.  It  is  held  that  if  cancer 
develops  on  chronic  ulcer  a  great  frequency  of  its  duodenal 
incidence  should  be  expected.  That  the  duodenum  has  a 
protective  mechanism  against  malignancy  appears  to  be 
shown  by  the  surgical  observation  that  only  rarely  does 
cancer  at  the  pylorus,  on  the  stomach  side,  pass  to  the  duo- 
denum by  direct  extension.  In  our  series  but  four  such 
instances  were  noted.  The  difference  in  the  character  of 
the  tissue  in  which  the  chronic  ulcer  is  implanted  is  also 
demonstrated  by  the  fact  that  it  is  not  uncommon  to  find 
that  primary  ulceration  of  the  duodenum  which  extends  up 
to  the  pylorus,  assumes  malignant  characteristics  on  its 
gastric  side  while  the  ulcer  on  the  duodenal  side  remains 
benign.  There  are  6  such  cases  in  our  series.  Recurrences 
after  removal  of  cancer  are  extremely  rare  in  the  duodenum. 
We  have  also  5  cases  in  which  mahgnant  gastric  ulcer 
was  demonstrated  together  with  benign  calloused  duo- 
denal  ulcer.     Cancers    of    the    duodenum    occur   in    the 


THE    SIGNIFICANCE    OF   GASTRIC    ULCER  361 

great  majority  of  instances,  at  or  about  the  papilla  of 
Vater.  It  is  well  known  that  this  region  of  the  viscus 
suffers  traumatism  from  gall-stones,  altered  secretion  of  the 
liver  and  pancreas  and  from  infective  processes  of  the 
gall-tract.  The  upper  part  of  the  duodenum,  where 
ulcer  is  common,  is  relatively  immune  to  these  influences, 
and  from  the  intense  acidity  and  the  associated  pepto- 
lytic  power  of  the  gastric  juice,  which  may  irritate  gastric 
ulcers.  Further,  food  remains  but  a  brief  time  in  the  duo- 
denum. It  is  rapidly  passed  on  into  the  jejunum,  where 
it  stays  but  briefly.  This  region  is  also  almost  cancer- 
free.  The  chyle,  however,  passes  more  slowly  through 
the  ileum,  and  as  the  ileo-cecal  valve  is  approached,  malig- 
nant processes  again  appear.  The  cecum  and  ascending 
colon  are  common  grounds  of  cancer. 

(c)  Pathologists  readily  grant  that  there  is  a  type  of 
gastric  affection  which  they  class  as  ''ulcus  carcinoma- 
tosum."  They  demonstrate  this  generally  at  post-mortem. 
They  do  not,  however,  explain  why  this  type  of  ulceration 
exists,  by  revealing  any  characteristic  changes  in  the 
gastric  mucosa  in  which  it  occurs,  nor  do  they  show  that 
from  its  beginning  it  was  not  anything  else  than  malignant. 
They  are  willing  to  grant  that  it  is  something  different 
from  primary  cancer  which  later  ulcerates,  but  just  what 
this  difference  is  they  do  not  state.  This  type  of  affection 
appears  curiously  to  exist  as  an  isolated  entity  with  no 
explanation  of  its  existence  or  prophecy  as  to  its  future 
course. 

(d)  Clinicians  hold  that  malignant  ulcer  exists  in  from  3 
to  6  per  cent,  of  all  ulcers  of  the  stomach  (Fenwick,  Rosen- 
heim and  others) .  The  various  observers,  however,  do  not 
detail  just  how  to  segregate  this  group  clinically  from  benign 
chronic   gastric  ulcer,   nor   do   they  offer  suggestions   of 


362  CANCER  OF  THE  STOMACH 

guidance  for  the  determination  of  just  what  chronic  ulcers 
are  destined  to  pursue  this  course. 

In  our  series  there  were  239  cases  which,  up  to  within 
an  average  time  of  6.1  months  before  being  microscopically 
demonstrated  as  cancer,  showed  nothing  to  indicate  that 
were  a  laparotomy  to,  be  performed  in  that  period  anything 
other  than  benign  chronic  calloused  gastric  ulcers  would  be 
found.  Only  the  subsequent  course  or  the  examination  of 
fresh  tissue,  using  high  magnification,  at  operation,  revealed 
the  true  nature  of  the  affection.  In  this  group  of  cases 
cancerous  ulcers  were  found  on  laparotomy  in  105  (43.9 
per  cent.)  and  extensive  carcinomas,  with  or  without 
ulceration,  in  134  (56.1  per  cent.).  Of  the  183  cases  with 
a  clinical  history  of  primary  carcinoma,  ulcus  carcino- 
matosum  was  demonstrated  in  28  (15.8  per  cent.),  while 
in  154  (84.2  per  cent.)  extensive  growth  was  found.  Of  the 
106  cases  with  clinical  history  or  irregular  gastric  ulcer  in 
the  precancerous  stage,  ulcus  carcinomatosum  was  shown 
in  22  (20.7  per  cent.)  and  in  84  (79.2  per  cent.)  exten- 
sive involvement,  with  or  without  secondary  ulceration. 

These  observations  suggest  several  points.  Develop- 
ment and  careful  interpretation  of  the  early — the  pre- 
cancerous— history  permits  patients  coming  to  laparotomy 
at  a  stage  when  in  more  than  one-half  of  the  instances  the 
maximum  advantage  of  localization  of  the  disease  is 
available,  and  hence  the  maximum  benefit  accrues  to  the 
individual  case.  In  about  one-fifth  of  the  cases  of  so-called 
primary  and  gastric  cancer  ulcus  carcinomatosum  can  be 
demonstrated  at  operation,  and  these  appear  to  be  generally 
favorable  cases  for  operative  procedure,  compared  to  their 
fellows.  This  is  especially  to  be  emphasized  inasmuch  as  it 
has  been  shown  by  MacCarty  and  Blackford  that  time- 
duration  of  symptoms  bears  no  proportionate  relation  to 


THE    SIGNIFICANCE    OF    GASTRIC   TLCER  363 

the  size  and  extent  of  involvement  of  the  Ij^mph  nodes,  and 
that  the  operative  and  the  ultimate  mortality  are  in  direct 
proportion  to  the  amount  of  involvement  of  the  lymph 
nodes. 

It  would  appear  from  the  brief  consideration  of  the 
objections  to  the  interpretation  of  the  so-called  '"precan- 
cerous" history  with  respect  to  the  succeeding  neoplasm 
having  developed  an  earlier  benign  chronic  gastric  ulcer, 
that  so  far  as  we  can  judge,  cUnically,  the  careful  develop- 
ment of  such  history  furnishes  extremely  valuable  diag- 
nostic and  prognostic  information.  It  would  appear 
from  the  facts  submitted  that  such  interpretation  allows 
the  greatest  degree  of  operative  benefit  with  the  minimum 
of  operative  risk.  These  facts  have  especialh-  to  be  con- 
sidered when  we  recall  that  we  have  no  better  clinical  guide 
and  that  those  who  object  to  the  significance  of  the  ''pre- 
cancerous" history  have  nothing  better  to  offer. 

SIGNIFICANCE  OF  CLINICAL  SYMPTOMS 

Periodicity  of  Symptoms. — One  of  the  strongest  clinical 
evidences  in  the  diagnosis  of  chronic  gastric  ulcer  is  the 
periodic  recurrence  of  dyspeptic  symptoms  with  perfect 
or  fair  health  between  the  attacks.  Graham,  Friedenwald 
and  ourselves  have  pointed  this  out.  In  239  of  the  cases 
furnishing  the  material  for  this  report  in  which  there  was  a 
precancerous  history  of  digestive  disturbance,  81  per  cent, 
complained  of  attacks  of  discomfort  in  that  period;  in  13.3 
per  cent,  the  attacks  were  of  rare  occurrence,  and  4.7  per 
cent,  had  had  continuous  disturbance.  When  the  period 
of  mahgnancj^  supervened  on  the  intermittent  dyspeptic 
storm  the  affection  was  continuous  and  progressive  in  more 
than  99  per  cent.,  irrespective  of  the  earlier  history.  In 
the  182  cases  making  up  the  "primary"  cancerous  group, 


364  CANCER  OF  THE  STOMACH 

continuous  disturbance  was  noted  in  95.1  per  cent,  and 
frequent  periodic  attacks  in  4.8  per  cent. 

Types  of  Pain. — In  the  group  of  cases  comprising  cancer 
following  previous  dyspepsia,  severe  pain  and  colic  were 
noted  in  23  per  cent.,  steady  ache  in  48  per  cent,  and 
abdominal  discomfort  in  28  per  cent.  In  the  primary 
cancer  group  coHcky  pain  was  noted  in  but  6.6  per  cent., 
steady  ache  in  32.4  per  cent.,  and  vague  discomfort  or 
•^ bloat"  in  56  per  cent.,  while  in  4.3  per  cent,  there  was  no 
abdominal  discomfort  whatever.  Opiate  relief  of  pain 
was  required  in  6.5  per  cent,  of  the  first  group  of  cases,  and 
in  2  per  cent,  of  the  second  group. 

Food  Relation  of  Abdominal  Pain  or  Distress. — In  the 
diagnosis  of  chronic  gastric  ulceration,  the  reUef  of  dis- 
comfort by  the  ingestion  of  food  (if  this  form  of  relief  be 
fairly  constant)  is  granted  to  be  a  most  valuable  diagnostic 
sign.  In  a  chronic  dyspeptic  its  continuous  presence  is 
often  almost  pathognomonic  for  ulcer.  At  the  stage  when 
the  cases  in  our  series  came  under  observation,  of  the  dys- 
pepsia-preceding-maHgnancy  group,  food  ease  was  present 
in  20.9  per  cent.,  food  aggravation  in  46.4  per  cent.,  food  of 
negative  significance  in  27.4  per  cent.,  and  uncertain  in 
5.1  per  cent.  In  the  group  of  primary  cancers,  food  ease 
was  noted  in  but  3.2  per  cent.,  food  aggravation  in  57.6  per 
cent.,  food  of  negative  significance  in  36.8  per  cent.,  and  of 
uncertain  effect  in  2.1  per  cent. 

Hemorrhage. — Intermittent  bleeding  (melena,  hematem- 
esis)  is  considered  as  almost  conclusive  evidence  that  peptic 
ulcer  exists.  While  only  but  from  22  to  40  per  cent, 
of  gastric  ulcers  bleed  (Friedenwald,  Smithies),  yet  when 
hemorrhage  occurs,  other  things  being  equal,  it  is  clinically 
assumed  that  ulcer  is  present.  In  the  series  of  cancers  here 
analyzed,  hemorrhage  was  noted  in  97  cases.     Of  the  group 


THE    SIGNIFICANCE    OF   GASTRIC   ULCER  365 

designated  by  history  symptomatology  as  malignancy- 
foUowing-ulcer,  hemorrhage  occurred  in  62.9  per  cent.; 
in  the  group  styled  from  early  history  ''irregular"  ulcer 
hemorrhage  occurred  in  19.5  per  cent.,  while  in  the  group 
of  ''primary"  cancers  hemorrhage  occurred  in  16.5  per 
cent.  Of  the  whole  number  bleeding,  52  per  cent,  bled  at 
least  2  years  prior  to  their  coming  under  observation, 
while  42  per  cent,  had  bled  within  2  years  of  that  time. 
In  6  per  cent,  the  time  of  hemorrhage  was  not  determined. 
Of  those  who  bled  within  the  2-year  period,  77.5  per  cent, 
were  cases  comprising  the  non-primary  cancerous  group. 

Anemia. — Of  one  or  more  estimations  of  hemoglobin  in 
250  of  the  cases,  the  average  hemoglobin  was  69.6  per  cent, 
for  the  primary  cancerous  group  and  67.2  per  cent,  for  the 
dyspepsia-bef ore-cancer  class.  The  average  for  the  series 
was  68.1  per  cent. 

Vomiting. — Of  the  entire  series  326,  or  57.5  per  cent., 
of  the  cases  vomited,  and  of  this  number  57  per  cent, 
vomited  daily.  Of  the  series,  132  (40.5  per  cent.)  exhibited 
delayed  vomiting.  In  but  58  (15  per  cent.)  was  the 
vomitus  dark  or  "coffee-ground." 

SIGNIFICANCE  OF  PHYSICAL  EXAMINATION 

Tumor  or  ridge  in  the  abdomen  (generally  epigastric) 
was  demonstrated  in  411  instances  (72.6  per  cent.).  It  was 
movable  in  63.6  per  cent.  Of  the  primary  cancerous 
group  tumor  was  present  in  39.8  per  cent.,  while  in  the 
ulcer-cancer  class  it  was  shown  in  60  per  cent. 

Metastases  were  demonstrated  in  86  cases  (14.7  per 
cent.)  before  laparotomy,  and  were,  in  the  order  of  fre- 
quency, rectal  and  pelvic,  cervical  and  axillary,  navel 
and  abdominal  wall,  and  in  the  groin.  In  the  primary 
cancerous    group,    metastases   were  present   in  20.8   per 


366  CANCER  OF  THE  STOMACH 

cent,  and  in  the  non-primary  class  in  13  per  cent.  When 
such  metastases  were  present,  the  cases  were  generally 
inoperable. 

SIGNIFICANCE  OF  TEST-MEAL  FINDINGS 

The  secretory  function  of  the  stomach  was  determined 
by  means  of  the  Ewald  breakfast.  It  was  preceded  12 
hours  by  a  motor-meal  after  the  suggestions  of  Strauss 
and  Hansmann.  Routine  quantitative  and  qualitative 
estimations  were  performed  by  the  Topfer  method. 

There  is  not  space  here  to  go  into  elaborate  detail 
of  the  information  derived  from  examination  of  gastric 
contents  in  our  series  of  566  cases  of  cancer.  A  few  of 
the  more  important  points  will  be  detailed,  and  the  com- 
plete report  reserved  for  a  subsequent  paper. 

Food  Remnants. — Motility  was  interfered  with  in  73.9 
per  cent,  of  the  entire  series.  Of  the  primary  cancerous 
group,  remnants  were  present  in  64.8  per  cent,  and  in  the 
non-primary  class  in  74.2  per  cent. 

Acidity  of  Gastric  Extract.— In  the  primary  cancerous 
group  there  were  55.4  per  cent,  of  cases  in  which  hydro- 
chloric acid  was  absent,  in  11.5  per  cent,  hydrochloric  acid 
was  between  20  and  50.  In  this  group  79  per  cent,  had 
total  acidity  under  50,  and  84  per  cent,  had  combined 
acidity  and  acid  salts  under  50. 

In  the  non-primary  cancerous  group,  free  hydrochloric 
acid  was  absent  in  49  per  cent.,  in  20  per  cent,  it  was 
between  20  and  50,  and  in  46.3  per  cent,  it  was  under  50. 
Total  acidity  was  below  50  in  78  per  cent.,  and  combined 
acidity  and  acid  salts  below  50  in  90  per  cent. 

Lactic  Acid. — In  the  primary  cancerous  group  this 
was  demonstrated  in  52.2  per  cent.,  while  in  the  non-pri- 
mary class  it  was  present  in  44.9  per  cent. 


THE    SIGNIFICANCE    OF    GASTRIC   ULCER  367 

Occult  Blood.- — This  was  shown  (benzidin  or  guaiac  tests) 
in  73  per  cent,  of  the  primary  cancerous  class,  and  in  77 
per  cent,  of  the  non-primary  group. 

Microscopic  Examinations  of  Gastric  Extracts. — These 
were  made  on  the  last  146  cases  of  gastric  carcinoma  by  the 
agar-differential-stain  method  devised  by  the  author. 

Oppler-Boas  Bacilli. — This  form  of  organism  was  dem- 
onstrated in  93.8  per  cent,  of  all  the  cases.  In  this  same 
series,  yeasts  were  shown  in  50.7  per  cent,  and  sarcines  in 
17  per  cent.  Oppler-Boas  baciUi  and  yeasts  were  com- 
bined in  30  per  cent.,  Oppler-Boas  bacilli  and  sarcines  in  10 
per  cent,  and  Oppler-Boas  bacilli  together  with  yeasts 
and  sarcines  in  9.2  per  cent.  Cells  showing  atypical 
mitoses  were  present  in  5  cases. 

Special  Tests. — In  141  instances  of  demonstrated  cancer 
the  glycyltryptophan  test  was  made.  It  was  positive  in 
40  per  cent.  We  have  already  analyzed  much  of  the 
material  at  another  place  in  this  book. 

In  31  cases  the  hemolytic  reaction  to  alien  erythrocytes 
in  vitro  was  positive  in  47.2  per  cent. 

Woodyatt  and  Jacques  have  recently  pointed  out  that 
in  gastric  cancers  an  ereptic  ferment,  as  estimated  by  the 
modified  formaldehyde  titration  method  suggested  by 
Sorenson  and  Schiff,  can  be  demonstrated  in  excess  in  the 
gastric  extract  that  has  been  passed  through  a  Berkefeld 
filter.  Our  experience  with  the  original  procedure  is 
briefly  summarized  as  follows:  The  average  formaldehyde 
index  of  57  cases  of  gastric  cancer  was  21.  The  average 
index  of  40  cases  of  benign  gastric  ulcer  was  10.8  and  the 
average  index  in  75  cases  of  duodenal  ulcer  was  11.9. 
In  17  cases  of  achylia  gastrica,  the  average  formaldehyde 
titration  index  was  14.1,  of  10  cases  of  pernicious  anemia, 
14.5,  and  in  5  cases  of  carcinomas  of  the  liver,  4.25.     It 


368  CANCER  OF  THE  STOMACH 

would  appear  that  in  some  instances,  the  estimation  of 
the  ereptic  power  of  gastric  juice  toward  peptone  solu- 
tions is  of  some  value  when  taken  in  consideration  mth 
clinical  history  and  sjTnptomatology. 

Wolff-Junghans'  Test  for  Soluble  Albumin. — By  this 
quantitative  estimation  method  we  in  this  series  have  made 
260  tests  on  gastric  extracts  showing  achyha  or  free  hydro- 
chloric acid  below  20  from  cases  in  this  series.  There  were 
83  cases  of  gastric  cancer.  The  reaction  was  positive  in 
86  per  cent.  In  this  group  there  were  20  cases  of  lesser 
curvature  and  cardiac  malignancy,  and  the  reaction  was 
positive  in  75  per  cent.  Of  11  cases  of  ulcus  carcinoma- 
tosum  without  gastric  retention  the  reaction  was  positive 
in  10  cases,  or  90.9  per  cent.  In  11  cases  of  extragastric 
carcinomas  (liver  and  gall-tract)  the  reaction  was  positive 
in  10  per  cent.;  in  17  cases  of  achyha  gastrica,  positive 
in  17  per  cent.  It  would  seem  that  this  test  is  of  value 
when  taken  in  consideration  with  other  evidence  in  car- 
cinomas not  associated  with  pjdoric  obstruction  or  pal- 
pable tumor,  for  example,  growths  at  the  cardia,  the 
fundus,  high  on  the  lesser  curvatm^e,  and  on  the  posterior 
wall,  and  in  cases  in  which  a  large  carcinoma,  with  con- 
siderable induration,  holds  a  pylorus  open. 

SURGICAL  CONSIDERATION 

Location.^ — In  210  cases  (39  per  cent.)  the  ulcus  car- 
cinomatosum  or  the  growth  was  at  the  pylorus;  in  27.1 
per  cent,  on  the  lesser  curvature  near  the  pylorus;  in  19.3 
per  cent,  general;  in  7.2  per  cent,  on  the  posterior  waU, 
and  in  4.2  per  cent,  at  the  cardia.  The  greater  curv^e  was 
involved  in  1.1  per  cent.,  the  fundus  in  0.75  per  cent.,  and 
the  anterior  wall  in  0.37  per  cent.  In  9  cases  there  were 
simple  and  mahgnant  ulcers  associated  in  the  same  stomach, 


THE    SIGNIFICANCE    OF   GASTRIC    ULCER  369 

and  in  5  cases  simple  duodenal  ulcer  and  malignant  gastric 
ulcer. 

The  figures  for  location  are  to  be  contrasted  with  those 
of  Welch,  Brinton,  Lebert  and  others.  These  authorities 
observed  generally  the  terminal  results  of  cancer  of  the 
stomach;  nor  were  their  observations  always  in  a  con- 
secutive series,  examined  by  uniform  procedures.  To 
any  one  who  has  had  access  to  post-mortem  material  the 
difficulties  connected  with  primary  localization  of  gastric 
neoplasms  need  not  be  explained.  The  localization  figures 
of  our  series,  however,  closely  correspond  to  the  location 
of  chronic,  calloused  gastric  ulcer,  as  shown  by  the  tables 
of  Welch  and  myself. 

Lymph  nodes  were  involved  in  71  per  cent.,  irrespective 
of  the  early  or  late  history.  In  22.2  per  cent.,  there  was 
no  lymph-node  involvement  and  these  cases  were,  as  a 
rule,  favorable  for  operation.  Free  fluid  in  the  abdomen 
was  present  in  3.9  per  cent.     These  were  inoperable  cases. 

There  were  16  cases  in  which  a  carcinomatous  ulcer 
had  been  previously  excised,  but  in  which  the  involvement 
of  the  lymph  nodes  (often  microscopic  only)  had  been 
noted — in  which  the  subjects  later  returned  with  huge 
inoperable  masses  in  the  epigastrium. 

Twelve  per  cent,  of  the  patients  died  within  6  months 
following  operation,  but  36.6  per  cent,  remained  well  for 
more  than  3  years,  and  22  per  cent,  remained  well  over  5 
years. 

Pathology. — It  is  not  feasible  to  give  here  a  detailed 
description  of  the  specimens  secured  at  laparotomy  in  this 
series  of  gastric  cancers,  and  only  a  gross  summary  will  be 
made. 

The  specimens  were  first  examined  in  frozen  section 
within  a  few  minutes  after  their  removal  from  the  patients. 

24 


370  CANCER  OF  THE  STOMACH 

They  were  next  fixed  in  Melinkow's  modification  of  Kaiser- 
ling's  fluid  and  again  sectioned  and  examined. 

Full  reports  have  been  made  by  MacCarty  and  recently 
some  of  the  specimens  furnish  part  of  the  study  of 
Wilson  and  McDowell. 

Types  of  Growth. — Adenocarcinomas  were  demonstrated 
in  556  instances  (98.2  per  cent.);  colloid  carcinomas,  '5 
times;  fibromas,  4  times,  and  sarcoma  once.  In  155 
instances  (27.4  per  cent.)  ulcera  carcinomatosa  were  shown. 
These  may  have  been  primarily  such,  had  formed  from  pre- 
vious chronic  ulcer  or  had  resulted  from  surface  pro- 
teolytic ulceration  of  preceding  cancer.  It  is  often  im- 
possible to  say,  without  clinical  history  or  test-meal 
findings,  whether  an  ulcus  carcinomatosum  developed  as 
such  or  whether  it  is  a  secondary  result  of  a  ''primary" 
cancer.  At  the  present  stage  of  our  knowledge,  the  sur- 
gical pathologist  can  positively  say  only  that  in  a  given 
specimen  of  chronic,  indurated  gastric  ulcer,  cancer  is,  or 
is  not  present.  There  appears  to  be  a  border-line  class, 
however,  in  which  surgical  pathologists  of  the  widest 
experience  in  the  examination  of  fresh  or  fixed  tissue  can 
often  distinguish  cellular  arrangement  or  intracellular 
change  of  such  nature  as  to  warrant  their  stating  that  the 
process  is  ''precancerous."  Not  infrequently  the  subse- 
quent course  of  the  ailment  bears  out  the  histologic 
prophecy. 

In  the  experience  of  Wilson  and  MacCarty,  71  per  cent, 
of  153  cases  of  undoubted  gastric  carcinomas  presented 
gross  and  microscopic  evidence  of  previous  ulcer.  These 
observers  also  demonstrated  that  68  per  cent,  of  resected 
chronic  ulcers  of  the  stomach  and  duodenum  (the  latter 
furnishing  a  very  small  proportion  of  cases)  were  associated 
with  cancer.     In  several  instances,  MacCarty  noted  that 


THE    SIGNIFICANCE    OF    GASTRIC    ULCER  371 

the  presence  of  erosions,  simple  round  ulcer  and  ulcus 
carcinomatosum  in  the  same  specimen  suggested  possibili- 
ties of  transition  corresponding  to  that  shoT\Ti  by  Wooley 
in  cases  of  adrenal  tumor.  MacCarty  has  emphasized 
the  diflB.culties  of  always  differentiating  between  simple 
hyperplasia  and  mahgnant  hyperplasia.  He  suggests  that 
hyperplasia  is  a  forerunner  of  malignancy,  that  hyperplasia 
varies  in  degree,  that  cancer  is  malignant  hyperplasia,  which 
also  varies  in  degree,  and  that  some  degrees  of  both  proc- 
esses are  indistinguishable  histologically.  This  \dew  is  well 
within  the  opinion  of  Adami.  It  seems  to  be  partially 
substantiated  by  the  recent  work  of  Drew  and  of  Levin  in 
experimental  tissue  proliferation  and  inoculation  of  malig- 
nant tumors. 

Association  of  Malignant  and  Benign  Processes. — In  this 
series  of  gastric  cancers  there  were  five  instances  of  simple 
ulcer  of  the  duodenum  associated  with  malignant  gastric 
ulcer.  In  9  cases,  simple  and  mahgnant  ulcers  were  found 
in  the  same  stomach.  Independent  cancer  of  the  stomach 
and  of  the  duodenum  was  demonstrated  once.  There 
were  2  cases  of  multiple  gastric  cancers.  Six  times  it  was 
observed  that  mahgnant  gastric  ulcers  stopped  sharply 
when  duodenal  mucosa  was  reached,  but  in  seven  in- 
stances of  extensive  gastric  cancers  it  was  shown  that  the, 
duodenum  was  secondarily  involved  by  direct  extension. 

REFERENCES 

Bkinton:  Diseases  of  the  Stomach,  2nd  edition,  pp.  124,  133. 

Bolton,  C:  Ulcer  of  the  Stomach,  1913,  London,  p.  6. 

BoLTOx:  Quarterly  Journal  of  Medicine,  Vol.  v.  No.  20,  p.  438;  Brit. 

Med.  Jour.,  1910,  Vol.  i,  p.  1222;  Waus.  Path.  Sect.  Ray.  Soc.  Med. 

(London),  1910,  Vol.  iv,  No.  2,  p.  57;  Jour,  of  Path,  and  Bact.,  1910, 

Vol.  xiv,  p.  418. 

1.  Smithies:  Am.  Jour.  Med.  Sc,  1913,  March,  p.  340. 

2.  Graham:  Collected  Papers  by  the  Staff  of  St.  Marj^'s  Hospital,  i.  111. 


372  CANCER  OF  THE  STOMACH 

3.  Shutz:  Wien.  klin.  Wchnschr.,  1912,  Oct.  10,  p.  1513. 

4.  Fkiedexwald:  Am.  Jour.  ]Med.  Sc,  1912,  August,  p.  157. 

5.  OsLER  AXD  ]McCrae:  Cancer  of  the  Stomach,  Practice  of  ]Medicine, 

1912. 

6.  WiLSOX  AXD  ]MacCarty:  Am.  Jour.  Med.  Sc,  1909,  December,  p. 

846. 

7.  MacCarty:  Surg.,  Gynec.  and  Obst.,  1910,  ^lay,  p.  -449. 

8.  Osler:  Philadelphia  Med.  Jour.,  1900,  p.  245. 

9.  Chesxel:  These  de  Paris,  1877. 

10.  Patersox:  Surgery  of  the  Stomach,  1913,  p.  248. 

11.  Gressot:  Berl.  klin.,  Wchnschr.,  1912,  xHx,  22. 

12.  Fextvick:  Quoted  by  Paterson,  Surgerj^  of  the  Stomach,  1913,  p. 

248. 

13.  Rosenheim:  Ztschr.  f.  khn.  Med.,  Breslau,  1890,  \-ii,  116. 

15.  Graham:  Prominent  Symptoms  in  the  Diagnosis  of  Gastric  and 

Duodenal  Ulcers,  The  Journal  A.  M.  A.,  1908,  Aug.  22,  p.  651. 

16.  Smithies:  A  Method  for  the  Microscopic  Examination  of  Gastric 

Extracts  and  of  Feces,  Arch.  Int.  Med.,  1912,  June,  p.  736. 

17.  WooDYATT,  R.  T.  AXD  Jacques,  J.  L. :  The  Peptolj^ic  Power  of 

Gastric  Juice  and  Sahva  with  Special  Reference  to  the  Diagnosis 
of  Cancer,  Arch.  Int.  Med.,  1912,  December,  p.  560. 

18.  SoREXSON  and  Schiff:  Zeitschr.  f.  phj-siol.  Chem.,  1909,  xiii,  27. 

19.  Welch:  Cancer  of  the  Stomach,  American  System  of  Medicine,  ii. 

20.  Brixtox:  Brit,  and  For.  Med.-Chir.  Rev.,  1857,  J&misury. 

21.  Lebert:  Traite   pratique   des  maladies   cancereuses,   Paris,    1851, 

p.  97. 

22.  Welch:  Simple  Ulcers  of  the  Stomach,  Pepper's  System  of  Medi- 

cine, ii. 

23.  Wooley:  Tr.  Assn.  Am.  Phys.,  1902,  Xo.  17,  p.  627. 

24.  Ad  ami:  ^Malignancy;  Principles  of  Patholog}',  p.  616. 

25.  Drew:  Jour.  Path,  and  BacterioL,  1912,  July,  p.  42. 

26.  Levix:  Jour.  Exper.  Med.,  1912,  Xo.  12,  p.  149. 


CHAPTER  IX 
GASTRIC  CANCER  IN  THE  YOUNG 

We  have  tabulated  18  instances  of  gastric  cancer  in 
individuals  under  age  31.  These  occurred  in  my  study  of 
the  records  of  921  pathologically  demonstrated  cases  of 
cancer  of  the  stomach.  It  is  thought  that  their  analysis 
will  demonstrate  certain  facts  of  value  in  anticipating  or 
detecting  this  grave  malady  at  an  age  when  it  is  not 
commonly  suspected. 

Those  who  wish  to  familiarize  themselves  with  the 
literature  on  this  subject  may  refer  to  the  excellent  mono- 
graphs of  Welch,  Osier  and  McCrae,  and  Dock. 

A  summary  of  these  previous  reports  on  gastric  cancer 
in  the  first  three  decades  may  be  of  service.  Six  instances 
(often  rather  dubious  as  to  cancer)  have  been  recorded  be- 
low the  age  of  10.  In  the  second  decade  15  cases  are  de- 
scribed. In  but  9  of  these  there  were  rehable  pathologic 
reports.  In  the  thirteen  instances  occurring  in  the  third 
decade,  few  descriptions  are  accompanied  by  pathologic 
findings.  Many  of  the  patients  in  this  group,  however, 
appeared  to  have  been  affected  with  a  gastric  malady, 
seemingly  malignant. 

Incidence. — The  relative  frequency  of  gastric  cancer  in 

the  young  varies  with  the  individual  series  studied.     In  a 

small  series  as,  for  example,  the  beautifully  analyzed  150 

cases   of   Osier   and   McCrae,    the   proportion  was   4   per 

cent.     In  a  large  series,  collected  for  statistical  purposes 

from  various  non-related  sources  throughout  the  world, 

as  in  the  2,038  instances  tabulated  by  Welch,  the  ratio  was 

373 


374  CANCER  OF  THE  STOMACH 

2.8  per  cent.  In  my  own  group  of  921  consecutive  cases, 
examined  by  a  uniform  method  (and  a  distinctly  American 
experience),  the  percentage  was  2.17  per  cent.  Sex: 
There  were  12  females  and  8  males.  Age:  The  youngest 
patient  was  aged  18;  the  oldest  just  past  30  years.  The 
average  age  of  the  series  was  27.2  years.  Status:  Twelve 
patients  were  married.  In  two  instances  (12  per  cent.) 
there  was  a  family  or  blood-relationship  history  of  cancer. 
Only  twice  were  more  than  ordinary  indulgence  in  tobacco 
or  alcohol  noted.  Apparently  occupation  had  no  etiologic 
significance. 

Duration  of  all  Gastric  Complaints. — This  data  concerns 
but  sixteen  instances.  Most  useful  facts  are  brought  out 
by  study  of  this  phase  (see  Table  36).  It  will  be  noted  that 
the  shortest  time  was^  4  months,  while  in  one  instance  the 
gastric  disturbance  had  persisted  for  15  years.  The  aver- 
age length  of  time  of  the  disability  was  4.2  years. 

Consideration  of  the  earlier  part  of  those  histories  in 
patients  exhibiting  protracted  gastric  complaints  not 
infrequently  reveals  the  fact  that  there  is  in  the  early  stages 
a  different  clinical  presentation  of  the  disease  than  is 
exhibited  toward  its  end.  It  would  seem  that  the  ob- 
servation of  occasional  cases  of  cancer  in  which  the  dura- 
tion of  the  gastric  history  had  been  long  drawn-out, 
doubtless  led  such  clinicians  as  Dock  and  Mathieu  to 
venture  the  opinion  that  cancer  of  the  stomach  in  early 
life  runs  a  somewhat  slow  course.  This  opinion  appears 
well-founded  if  one  considers  both  the  ''pre-cancerous" 
and  the  evidently  cancerous  portions  of  the  history. 

Types  of  Gastric  Histories. — In  respect  to  types  the 
histories  divide  themselves  quite  sharply  into  two  groups : 
Group  1  includes  cases  in  which  there  appeared  a  gastric 
affection,  pernicious  in  nature  and  progressively  downward 


Test-meal 


Surgical  and  pathologic  findings 


14 

18 

^5 

15 

C4 

10 
10 

rs 

I}5 
S3 

M 


46 


14 


BNo    contents.    Tube       could 
;   not       be       passed     beyond 
cardia. 


30 


Pylorus 


General 


Pylorus 


Lesser 
curve 
and  py- 
lorus. 

Malig. 
ulcer 
on  less, 
curv. 

Lesser 
curva- 
ture. 

Pylorus 


Lesser 
curve 
and 
post, 
wall. 

Lesser 
curve 
and 
ant. 
wall. 

Post, 
wall. 


Lesser 
curva- 
ture 

Post, 
wall. 


Lesser 
curva- 
ture. 


High  on 
lesser 
curve 
and   at 
cardia, 

Lesser 
curva- 
ture. 


Infiltra- 
ting mass. 


Infiltra- 
ting mass. 


Nodule  (ul- 
cer?) size 
4  in. 

Huge   ma- 
lignant 
ulcer. 


Inop.  large]      -f 
adherent 


+  + 


+  + 
Peri- 
to- 
neum 
+  -I-  + 


Malignant 
ulcer. 

Inop._  infil- 
trating 
mass. 

Inoperable 


Malignant 
ulcer. 


Malignant 
ulcer. 


Large  ma- 
lignant 
ulcer. 

Huge   ma- 
lignant 
ulcer. 


Early  ma- 
lignant 
ulcer. 


Malignant 
ulcer. 


Huge   ma- 
lignant 
ulcer. 


Pylorus    Large 


0 
0 
+  + 


+  + 


+  + 


Pancreas 
and  liver. 


Pancreas, 
liver  and 
perito- 
neum. 

Liver  and 
perito- 
neum. 


0 


Pancreas 


0   Gall- 
stones. 


Pancreas 


Liver,  ova- 
ries, peri- 
toneum. 


Liver,  pan- 
creas, 
periton. 

Pancreas 


Carcin 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 

Carcin- 
oma. 


Carcin- 
oma. 


Carcin- 
oma. 


Carcin- 
oma. 

Carcin- 
oma. 


Carcin- 
oma. 


Carcin- 
oma. 


Carcin- 
oma. 


Carcin- 
oma. 


Posterior  gast.- 
ent. 


Explored 


Anterior  gast. 
ent. 


Explored 


Posterior  gast. 
ent. 


Witzel  jejunos- 
tomy. 

Posterior  gast.- 
ent. 

Explored 


Miculicz-Hart- 
man  -  Billroth 
No.  2  and 
post.  gast.- 
ent. 

MicuUcz-Hart- 
man  -  Billroth 
No.  2  and 
post.  gast.- 
ent. 

Pylorectomy 
and  post, 
gast. -ent. 

Milculicz-Hart 
man  -  Billroth 
No.  2  and 
post.  gast.- 
ent. 

Miculicz-Hart- 
man  -  Billroth 
No.  2  and 
post.  gast. 
ent. 
Explored 


Anterior  gast. 
ent. 


Died  in  6  mos. 


Died  1  day 
after  oper. 


Alive  3  years 

Died  in  6  mos. 

Lived  5  years 

AUve. 

Alive  2  years 

Died  in  1  yr. 

Alive  2  years. 

Died  8  mos. 

Alive  5  years 


Patient  died 
l\i  years  la- 
ter with  ova- 
rian metas- 
tases. 

Died_  1  year 
ovarian  and 
uterine  metas- 
tases. 

Alive  1  year 


Died     in    2li 
months. 


Anterior  gast.-   Died     in      12 
ent.  days. 


Table  36. — Clinical  Data  of  Gastric  Cancer  in  the  Young  (Author's  Study) 


"ppeTji- 


Uloer? 

Typical 
Gall- 


Epigaat. 
Epigaat. 


high  mid 
epigost. 


RC. 
I  2  to  3 


^^ieef- 


Clcrk. 


Houao- 


Night 
On   full 


Pood 


Typical 

Typical 


Epigast. 
Bpigoat. 


colics,  full. 


Surgical  and  patholoejo  findiaga 


G».„l 

Infiltra- 
ting mass 

Pylorua 

Nodule  (ul- 
cerT)  BiM 

Lesser 

Hugo    ma- 

2Ey- 

Sr°' 

TOlLs 

adherent 

'oS^'.- 

Malignant 
ulcer. 

Pjloru. 

L.«,er 

iDoperable 

AUvo. 


No.     2     and 


■  Pylorcotomy 

■  Alikuifcz-Hart 


Potient     died 


■  Miculioi-Hort- 


Died     in    2Vi 


0  In  this  ooluc 


indicates  liquid;  : 


GASTRIC    CANCER   IN   THE   YOUNG  875 

in  course,  in  patients  in  whom  there  had  been  no  previous 
gastric  ailment.  Group  2  comprises  a  number  of  cases  in 
which,  previous  to  the  time  at  which  they  came  under 
observation  for  a  gastric  disease  of  a  mahgnant  kind,  there 
had  been  gastric  complaints  which  frequently  conformed 
to  the  type  which  we  call  clinically  ''peptic  ulcer." 

Group  1. — Two  of  the  16  cases  studied  fall  into  this 
class.  The 'average  duration  of  all  symptoms  was  4.5 
months.  In  these  2  cases  the  disease  was  from  its  inception 
progressively  and  perniciously  downward  in  course  and 
type,  and  there  was  no  alteration  in  the  character  of  the 
affection.  There  were,  clinically,  rapid  emaciation,  con- 
tinuous abdominal  discomfort,  early  onset  of  vomiting, 
development  of  epigastric  tumor  and  departures  from  the 
normal  in  the  test-meal  analysis  (see  Table  36).  Laparot- 
omy revealed  large,  inoperable  growths,  with  extensive  in- 
volvement of  the  lymph  nodes  and  pancreas.  One  patient 
died  within  12  days  following  operation;  the  other  lived  a 
year. 

Group  2. — This  includes  14  cases.  These  patients  had 
been  affected  for  an  average  time  of  4.8  years  with  some 
gastric  malfunction.  In  type  the  early  part  of  their 
affection  had  been  roughly  classed  among  the  "dyspepsias." 
A  careful  analysis  of  the  character  of  these  dyspepsias  reveals 
•useful  facts.  In  five  instances  (36  per  cent.)  the  gastric 
complaint  and  course  had  fully  satisfied  the  symptom- 
complex  which  we  ascribe  clinically  to  peptic  ulcer.  In  4 
cases  (25  per  cent.)  so-called  ulcer  features  were  definite  at 
some  stage  in  the  early  period  (in  one  instance  in  this  group 
there  was  frank  gastric  hemorrhage).  In  4  other  cases 
(25  per  cent.)  the  long-term  history  previous  to  onset  of 
evident  malignancy  was  that  of  peptic  ulcer  of  irregular 
type.     In   the   remaining    case,    gall-stone    attacks    were 


376  CANCER  OF  THE  STOMACH 

typical  through  4  years,  and  the  stones  were  later  found  at 
laparotomy. 

The  second  part  of  the  histories  of  cases  making  up 
Group  2  was  typical  of  gastric  malignancy,  "\^^lile  this 
phase  differed  widely  in  character  from  the  early  manifes- 
tations, yet  it  could  in  nowise  be  distinguished  clinically 
from  the  whole  course  of  the  ailment  in  the  2  cases  making 
up  Group  1.  If  one  had  not  carefully  analyzed  the  early 
histories  of  these  14  cases  in  Group  2  he  could  have  in  no 
way  shown  their  cUnical  variation  from  cases  in  Group  1. 
The  period  of  e\ddent  maUgnancy  in  Group  2  averaged  7.8 
months  in  duration.  The  most  rapid  progress  was  3 
weeks;  the  most  protracted  nearly  3  years. 

It  might  be  useful  to  emphasize  the  fact  here  that  of 
this  group  of  gastric  cancer  cases  in  the  young  with  long- 
time histories,  86  per  cent,  satisfied  or  approximated  our 
present-day  clinical  complex  of  peptic  ulcer  at  some  time 
during  a  period  averaging  4.8  years,  previous  to  the  time 
when  the  course  became  malignant;  that  during  this  time 
medical  treatment  availed  nothing  and  the  surgical  oppor- 
tunity for  cure  was  usually  neglected;  that  the  cases  in  this 
group,  due  to  some  unknown  cause,  did  not  pursue  a  course 
of  chronicity  of  benign  type,  but  later  evidenced  malignant 
pointings,  and  that  the  mahgnant  course  of  the  cases  in 
this  group  exhibited  an  average  duration  nearly  half  again 
as  long  as  occurred  in  cases  of  Group  1  in  which  no  previous 
gastric  disorder  had  been  observed. 

Clinical  Data. — Appetite. — ^In  six  instances  (38  per  cent.) 
the  appetite  was  poor.  In  the  remaining  cases  it  was 
usually  fair. 

Bowels. — All  cases  exhibited  some  degree  of  constipation. 

Weight  Loss. — In  the  two  instances  of  short-term  cancer 
(the  so-called   '' primary  cancers"),   the   average   loss   of 


GASTRIC    CANCER    IX    THE    YOUNG  377 

weight  was  17  pounds.  In  the  early  period  of  the  group 
of  cases  with  long-term  histories,  weight  loss  generally 
occurred  during  the  ''spells"  of  the  disabihty,  but  was 
rapidly  regained  during  the  succeeding  quiescent  stages. 
In  some  of  these  spells  the  weight  loss  was  as  much  as  35 
pounds.  In  the  late  stage  of  cases  of  this  type  (the  mahg- 
nant  period)  the  weight  loss  averaged  31  pounds.  It 
was  continuous  and  accompanied  by  other  evidences  of 
cachexia.  Some  rapid  weight  losses  were  observed,  e.g., 
20  pounds  in  2  weeks. 

Abdominal  Pain  or  Distress. — In  some  degree,  this  was 
noted  in  all  patients.  It  was  commonly  located  indefinitely 
in  the  epigastrium,  but  occasionally  the  complaint  was  of 
distress  in  the  back  or  the  high  ''pit."  In  two  instances 
pains  of  so  severe  a  degree  and  of  such  spasmodic  char- 
acter were  noted  that  perforation  was  believed  to  have 
taken  place. 

In  the  2  cases  comprising  Group  1  above  ("primary 
cancers")  the  pain  was  never  severe,  never  definitely 
locaUzed,  was  continuous,  but  was  generally  aggravated 
by  the  ingestion  of  food  or  drink.  In  these  instances  the 
common  pain  relief  was  obtained  by  limiting  the  amount 
of  ingested  food,  vomiting  at  the  height  of  distress,  and, 
occasionally,  by  alkalies. 

Of  the  14  cases  included  in  Group  2  above  (those  in 
which  the  patients  had  had  gastric  distress  before  malig- 
nancy became  evident),  12  (85  per  cent.)  had  pain  in 
"spells"  or  "attacks."  In  7  instances,  the  pain  at  such 
times  had  borne  fairly  definite  relation  to  food  ingestion; 
in  4  instances,  even  when  malignancy  had  supervened,  the 
food  rehef  of  pain  persisted.  In  10  cases  former  food 
reUef  of  pain  had  changed  to  food  aggravation  of  pain,  as 
the  malignant  process  became  manifest.     In  this  group  of 


378  CANCER  OF  THE  STOMACH 

14  cases  the  common  modes  of  pain  relief  were  vomiting, 
lavage,  limited  or  varied  diet,  alkalies,  food  intake  and 
some  form  of  opiate. 

Abdominal  Tenderness. — This  was  exhibited  on  pal- 
pation by  all  patients.  In  38  per  cent,  it  was  located 
generally  in  the  epigastrium.  In  3  instances,  the  maximum 
tenderness  was  in  the  left  epigastrium.  In  rare  cases 
was  abdominal  tenderness,  such  as  is  characteristic  of 
chronic  ulcer  of  the  perforative  type,  noted  even  when 
laparotomy  showed  that  the  peritoneum  had  become 
extensively  involved. 

Epigastric  Tumor. — Tumor  was  palpated  in  6  cases 
(38  per  cent.)  in  the  entire  series  (see  Table  36).  In  but  one 
instance  was  a  large  mass  demonstrable.  In  the  cases 
presenting  no  definite  tumor,  peculiar  stiffness  of  the 
abdominal  wall  with  a  sense  of  deep  resistance  was  fre- 
quently observed. 

Four  times  free  fluid  was  shown  to  be  present  in  the 
abdominal  cavity  before  laparotomy.  These  were  in- 
operable cases.  In  three  metastases,  as  in  the  left  supra- 
clavicular region  and  pelvis,  were  noted  before  operation. 
These  patients  had  hopeless  involvement. 

Eructations  and  Pyrosis. — Such  were  commonly  noted 
particularly  when  gastric  motility  had  been  interfered 
with. 

Vomiting. — Vomiting,  with  or  without  nausea,  was 
observed  in  all  the  cases  at  some  time  (usually  in  the 
terminal  stage)  in  the  course  of  the  disease.  In  the  two 
"primary  cancers,"  vomiting  came  on  daily  soon  after 
taking  food,  was  large  in  quantity,  rancid  in  odor,  but 
never  "coffee  colored." 

In  the  fourteen  instances  in  which  malignancy  had  termi- 
nated a  long-term  gastric  history,  vomiting  occurred  from  1 


GASTRIC    CANCER   IN   THE   YOUNG  379 

to  8  hours  after  meals;  in  but  one  instance  was  it  '^coffee 
colored,"  in  all  instances  it  contained  food  particles,  was  of 
a  rancid  color  and  relieved  abdominal  distress.  In  8  cases 
"delayed"  vomiting  was  observed.  Such  sign  was  usually 
associated  with  pyloric  stenosis  and  huge,  dilated  stomach. 

Laboratory  'Data..— Blood. — In  the  fourteen  instances  in 
which  the  hemoglobin  was  estimated,  it  averaged  66  per 
cent.     The  range  was  from  25  per  cent,  to  70  per  cent. 

Stool. — In  ten  instances  (62.5  per  cent.)  altered  blood  was 
chemically  demonstrated  by  the  benzidin  or  the  guaiac 
tests. 

Test-meals. — In  fifteen  instances  facts  of  much  interest 
were  obtained  by  this  mode  of  examination  of  gastric 
function.  One  case  (No.  14,  see  Table  36)  returned  no 
information  by  test-meal  analysis  because  the  stomach  tube 
could  not  be  advanced  beyond  the  cardia.  There  was 
obstruction  due  to  extensive  local  growth. 

Gastric  Emptying  Power. — In  11  cases  (73  per  cent.) 
motility  w^as  interfered  with  and  there  w^as  retained  food 
at  the  end  of  12  hours.  In  such  instances,  dilation  of  the 
stomach  of  various  degrees  had  invariably  occurred. 

Gastric  Acidity. — In  no  case  was  achyha  shown.  The 
average  total  acidity  w^as  59.     It  ranged  from  28  to  64. 

Free  hydrochloric  acid  was  absent  in  but  one  instance. 
This  was  a  case  of  fulminant,  primary  cancer.  The 
average  free  hj^dro chloric  acid  estimation  for  the  entire 
series  was  26.  It  ranged  from  as  low  as  3  to  as  high  as  60. 
The  highest  free  hydrochloric  acidities  were  noted  in  asso- 
ciation with  large,  cancerous  ulcers. 

Combined  hydrochloric  acid  and  acid  salts  averaged  18.1 
per  cent.     It  ranged  from  0  to  50. 

Lactic  acid  was  demonstrated  by  the  modified  Uffelmann 
test  in  6  cases  (40  per  cent.). 


380  CANCER  OF  THE  STOMACH 

Altered  blood  was  proven  by  chemical  test  in  gastric 
contents  12  times  (80  per  cent.). 

Microscopic  Examination  of  Unfiltered  Gastric  Extracts. — 
In  but  6  instances  (40  per  cent.)  were  organisms  of  the 
Oppler-Boas  group  definitely  identified.  In  8  cases  (53 
per  cent.)  yeasts  and  sarcinae  were  present.  Microscopic 
food  bits  were  recognized  in  nearly  90  per  cent,  of  instances. 

The  Laparotomy  Findings. — Two  cases  had  been  ex- 
plored before  coming  to  us.  Both  the  patients  had  been 
operated  on  within  the  year.  At  both  abdominal  sections 
the  surgeon  had  made  a  clinical  diagnosis  of  ''benign" 
gastric  ulcer  of  the  chronic  type,  yet  both  of  these  patients 
were  dead  from  inoperable  gastric  cancer  before  a  year 
had  elapsed !  The  resection  of  the  ulcer  or  the  microscopic 
examination  of  a  bit  of  extirpated  tissue  at  the  time  of  the 
initial  laparotomy  doubtless  would  have  made  known 
earlier  the  prognosis  and  have  prevented  further  surgery. 
It  might  have  saved  life. 

Location  of  the  Malignant  Process. — Abdominal  section 
revealed  five  instances  in  which  the  pylorus  was  involved;  9 
cases  in  which  the  lesser  curvature  and  some  part  of  the 
surface  of  the  viscus  were  affected;  one  instance  of  infiltration 
at  the  cardia,  and  1  case  of  general  carcinosis. 

Lymph  nodes  had  been  invaded  in  14  out  of  the  16  cases 
in  this  series.  Nine  times  secondary  growths  were  demon- 
strated in  the  liver,  pancreas,  omenta  or  pelvic  organs. 

Character  of  Neoplasms. — In  eight  instances,  extensive 
ulcera  carcinomatosa  were  present.  They  were  of  the 
medullary  type.  In  the  remaining  cases,  adeno-carcino- 
matosa  of  the  common  type  were  demonstrated. 

Operative  Procedures  and  Outcome. — In  four  instances 
exploration  only  was  possible.  In  5  cases  some  form  of 
resection  was  performed  with  or  without  gastrojejunos- 


GASTEIC    CANCER    IX    THE    YOUNG  381 

tomy.     In  the  remaining  seven  patients,  ^'drainage  opera- 
tions" to  fit  the  case  at  hand  were  devised. 

Xine  patients  died  within  m  years  following  operation. 
To  the  other  patients  of  this  series  was  granted  a  lease  of 
life  of  from  2  to  more  than  5  years. 

REFERENCES 

1.  Welch:  Proceedings  Boston  Society  for  Medical  Improvement,  v, 

Appendix,  p.  109. 

2.  OsLER  AND  ]McCkae:  Cancer  of  the  Stomach,  Philadelphia,  1900, 

p.  16. 

3.  Dock:  Am.  Jour.  Med.  Sc,  1897,  June,  p.  665. 

4.  Mathieu:  Semaine  med.,  1895,  p.  225. 

Smithies:  Jour.  Am.  Med.  Assn.,  1914,  Xov.  21,  p.  1839. 

Note:  We  have  since  had  opportunity  of  obser^dng  three  other  cases. 
They  were  a  male  aged  24  and  tvro  females  aged  18  and  27. 
Thev  are  not  analvzed  in  the  data  herewith. 


CHAPTER  X 
DIFFERENTIAL  DIAGNOSIS 

General. — Every  case  of  chronic  dyspepsia  should  be 
broadly  considered  from  two  aspects,  namely,  the  surgical 
and  the  medical.  This  applies  with  especial  force  to 
instances  of  indigestion — chronic  or  of  recent  onset — in 
patients  above  35  years  of  age.  The  primary  principle  of 
differential  diagnosis  of  intraabdominal  disease,  or  disease 
with  intraabdominal  pointings,  is  that  of  segregating  the 
group  likely  to  be  benefited  by  laparotomy  from  that 
where  the  hope  of  reUef  lies  in  general  medical  care.  It 
is  admitted  that  this  division  of  cases  is  not  always  easily 
made.  Doubtful  instances  are  of  common  enough  oc- 
currence. There  is,  however,  too  much  unnecessary  and 
usually  valueless  quibbling  over  finer  points  of  differential 
diagnosis  in  abdominal  disease.  This  is  often  to  the 
patient's  detriment.  While  learned,  pseudo-scientific  in- 
vestigations are  being  carried  on,  or  while  certain  medical 
attendants  are  awaiting  the  appearance  of  their  pet 
differential  points,  not  infrequently  the  subject  of  the 
research  passes  beyond  any  form  of  aid.  Rash  surgery 
is  to  be  condemned,  but  a  sharp  scalpel  is  often  a  more 
satisfactory  differential  diagnostician  than  is  the  keenest 
mind,  medically. 

Exploratory  laparotomy  has  perhaps  been  needlessly 
urged  in  many  instances  of  chronic  dyspepsia.  In  these 
cases  it  is  not  infrequently  found  that  but  a  limited  study 
has  been  made  of  the  gastro-intestinal  functions  before 
such  laparotomy.     Not  rarely  one  could  have  accurately 

382 


DIFFEEEXTIAL   DIAGNOSIS  383 

prognosed  unsatisfactory'  surgical  findings  or  results  from 
operation  before  laparotomy,  if  routine  examinations  had 
been  systematically  carried  out.  "WTbile  there  is  a  tend- 
ency on  the  part  of  many  clinicians,  particularly  the  sur- 
geons, to  perform  abdominal  section  in  order  to  make 
optically  evident  intraabdominal  pathology',  yet  this 
procedure  must  not  be  condemned  as  a  diagnostic  method 
simply  because  groups  of  poorly  trained  surgeons  are 
getting  negative  results  by  it. 

WTien  every  case  of  chronic  dyspepsia  has  been  considered 
a  strictty  medical  one  before  it  is  admitted  to  be  surgical, 
exploratory  laparotomy  very  often  yields  results  which 
are  satisfactory  to  both  the  patient  and  clinician. 

Internists  have  not  been  backward  in  claiming  that 
abdominal  surgery  is  too  readily  resorted  to  for  the  purposes 
of  diagnosis,  and  that  such  procedure  is  essentially  the 
lazy  man's  way  of  elucidating  a  problem  which  could 
have  been  xery  well  worked  out  along  other  hues.  The 
internist's  position,  however,  is  not  whollj^  an  unassailable 
one.  While  much  ma}^  be  expected  from  the  medical  treat- 
ment of  gastric  ulcer  in  competent  hands,  it  is  a  fact 
that  the  large  majority  of  mahgnant  gastric  ulcers  are 
allowed  to  progress  to  the  hopeless  stage  before  they  are 
referred  to  the  surgeon. 

Mortahty  in  gastric  cancer  can  only  be  successfully 
attacked  by  a  greater  number  of  obstinate  peptic  ulcer 
cases  being  treated  surgically  than  is  at  present  the  vogue. 
The  physician's  waiting  until  the  so-called  clinical  picture 
of  gastric  cancer  appears,  is  practically  equivalent  to  sign- 
ing the  patient's  death  certificate.  From  what  has  already 
been  stated  in  Chapters  II  and  III,  it  is  quite  evident 
that  the  early  diagnosis  of  gastric  cancer  concerns  itseh 
with   the   recognition   of   chronic   calloused   peptic   ulcer, 


384  CANCER  OF  THE  STOMACH 

particularly  of  the  recurrent  form.  We  would  especially 
emphasize  this  point.  Inasmuch  as  it  cannot  be  too 
strongly  urged,  we  offer  the  following  summary  of  the 
essential  points  in  the  diagnosis  of  chronic  calloused  ulcer 
of  the  stomach  and  the  duodenum. 

GASTRIC  ULCER 

1.  Facts  Determined  from  History. — (a)  Frequently, 
dietetic  or  hygienic  irregularities.  Males  are  more  frequently 
affected  than  are  females. 

(6)  History  of  recurring  acute  infections.  (La  grippe,  tonsil- 
litis, exanthemata,  etc.).  Seasonal  relation  of  distress  not 
uncommon,  exacerbations  occurring  in  fall  or  spring. 

(c)  Association  with  disease  of  appendix  or  gall-bladder 
(with  which  ulcer,  especially  in  subjects  below  age  30,  is 
often  confused). 

{d)  Periodicity  of  complaint  occurs  in  from  75  to  85  per 
cent,  until  complications  set  in.  Between  '^ spells"  or 
attacks  of  indigestion,  so-called,  there  is  generally  good 
gastric  health.  Weight  is  not  infrequently  lost  during 
attacks  and  rapidly  gained  when  such  cease. 

(e)  Epigastric  distress  is  present  in  more  than  95  per 
cent.  It  varies  in  severity,  from  discomfort  to  severe, 
gnawing  or  cramp-like  pains.  Discomfort  has  point  of 
maximum  location,  subjectively,  in  practically  3  out  of 
4  cases.  Pain  has  usually  reached  its  height  within  4 
hours  following  meaJs.  Pain  comes  on  sooner  past  cibo 
in  ulcers  located  near  the  cardia  than  where  such  are  well 
toward  the  pylorus. 

(/)  Food  relief  of  distress  occurs  in  four  out  of  five  in- 
stances of  peptic  ulcer  of  the  uncomplicated  type.  Relief 
of  pain  frequently  bears  relation  to  amount  of  food  taken, 
i.e.,  a  large  meal  gives  longer  relief  than  a  small  one.     Pain 


DIFFERENTIAL    DIAGNOSIS  385 

is  also  relieved  by  vomiting,  the  taking  of  alkalies,  by  rest, 
diet  and  opiates. 

(g)  Vomiting  occurs  in  more  than  two-thirds  of  the  in- 
stances; vomitus  usually  comes  on  at  the  height  of  gas- 
tric distress  and  when  acidity  is  highest.  Vomitus  of  food 
that  has  lain  in  the  stomach  longer  than  6  hours  (''delayed 
vomit")  increases  as  complications  (stenoses  or  perfora- 
tion) develop.  Pyrosis,  water-brash,  eructations  and  sour 
belching  are  common  on  ordinary  diet. 

(h)  Hemorrhage  (hematemesis  or  melena)  occurs  in 
from  20  to  40  per  cent,  of  instances.  While  hematemesis  is 
more  frequent  than  melena,  yet  melena  alone  may  occur 
wholly  irrespective  of  the  location  of  the  gastric  ulcer. 
Severe  hemorrhage  is  accompanied  by  signs  of  shock 
and  collapse. 

2.  Facts  Obtained  by  Examination. — (a)  Patient  is  usually 
well  nourished  without  toxic  or  cachectic  appearance,  un- 
less pyloric  stenosis  or  ''hour-glass"  contraction  has  oc- 
curred. 

{h)  Average  hemoglobin  about  80  per  cent,  unless  severe 
hemorrhage  has  recently  taken  place. 

(c)  Area  of  epigastric  tenderness  in  region  of  pyloric  half 
of  stomach.  This  is  usually  in  the  mid-epigastrium,  but 
not  necessarily  so.  The  area  is  most  frequently  definitely 
local  where  acute  or  chronic  perforation  has  taken  place. 
A  tender  ridge  may  sometimes  be  palpated  where  a  large 
chronic  ulcer  exists. 

(d)  Dilated,  splashy  stomach  occurs  where  marked  pyloric 
spasm  exists  or  stenosis  has  taken  place.  If  this  is  ex- 
cessive, visible  peristalsis  (and  rarely,  "reverse"  peris- 
talsis) may  be  noted. 

3.  Facts  Secured  by  Laboratory  Examination. — (a)  Test- 
meal. — Motility  interfered  with  in  more  than  50  per  cent. 

25 


386  CANCER  OF  THE  STOMACH 

of  instances.  Gastric  acidity  increased  with  respect  to  free 
hydrochloric  acid  in  the  majority  of  non-stenosing  ulcers. 
In  stenosing  ulcers,  with  dilatation  of  the  stomach,  while 
free  hydrochloric  acidity  may  not  be  above  normal,  the 
total  acidity  is  increased  in  greater  ratio.  Blood  may  or 
may  not  be  present  in  gastric  extracts  (macroscopically  or 
by  chemical  test).  Lactic  acid  is  a  rare  finding.  Pepsin 
and  rennin  are  frequently  increased. 

Microscopically  where  gastric  dilatation  has  occurred, 
fermentative  changes  are  proved  by  the  finding  of  great 
numbers  of  budding  yeasts  and  of  sarcinse  (large  and 
small  types)  together  with  remnants  of  retained  food. 

(6)  Stool  may  show  nothing  pathologic.  Recent  hem- 
orrhages generally  result  in  the  passage  of  "tarry"  stools 
for  several  succeeding  days.  Perforation  of  an  ulcer  to 
the  pancreas,  not  infrequently  brings  on  pancreatic  in- 
efficiency with  passage  of  stools  containing  undigested  food. 

During  periods  of  the  ulcer's  activity,  if  the  patient  is 
kept  upon  meat-free  or  milk  diet  for  several  days,  at  the 
end  of  such  time  the  stool  may  be  shown  by  chemical 
tests  (benzidin  or  guaiac)  to  contain  blood.  Progressive 
ulcers,  or  ulcers  undergoing  cancerous  change,  generally 
show  blood  constantly  in  the  stools  by  chemic  tests. 

(c)  X-ray  Findings. — In  many  instances  of  uncom- 
pUcated  ulcer  no  facts  are  returned  after  most  careful 
examination  by  both  fluoroscopic  or  plate  methods. 
Complicated  ulcers  (stenosing,  calloused,  ''hour-glass" 
producing,  perforating,  etc.),  are  recognizable  in  nearly 
three  out  of  four  instances  by  the  combined  screen  and 
plate  method. 

1.  Positive  Signs. — The  ''niche"  or  "accessory  cavity," 
indicating  calloused,  penetrating  ulcer. 

2.  Corroborative  Signs. — (a)  "Incisura,''  i.e.,    local   evi- 


DIFFERENTIAL    DIAGNOSIS  387 

dence  of  halting  peristaltic  rhA-timi  by  spastic  contraction 
of  circular  muscle  fibers  in  the  vicinity  of  an  ulcer.  Best 
brought  out  on  screen  examination  dm'ing  or  after 
palpation. 

(&)  "Hour-glass"  stomach  (biloculation).  This  may  be 
permanent  (callous  ulcer,  perforation,  adhesion),  or  tran- 
sient (local  spasm,  with  or  without  ulcer);  should  always 
be  proved  by  repeated  examinations  with  and  without 
an  antispasmodic  (atropine,  belladonna). 

(c)  Gastric  residue.  This  may  varA'  in  amount.  Its 
constant  demonstration  after  6  hours  means  atony  or 
stenosis.  Intermittently  it  may  result  from  extragastric 
or  gastric  pathology  causing  pyloric  spasm. 

(d)  Fixation  of  all  or  part  of  the  stomach  (perforation, 
adhesion,  fistula). 

(e)  Area  of  tenderness  to  palpation,  usually  localized  at 
some  part  of  the  stomach  shadow.  Should  always  be 
checked  by  repeated  examination  before  and  after  an 
antispasmodic. 

(/)  Alterations  in  gastric  peristalsis,  e.g.,  exaggerated  per- 
istalsis, intermittent,  frequently  associated  with  spasmodic 
closure  and  relaxation  of  the  pylorus.  Antiperistalsis  may 
be  seen  on  rare  occasions. 

DUODENAL  ULCER 

1.  Facts  Elicited  from  History. — (a)  Males  are  affected 
approximately  three  times  as  frequently  as  females.  Be- 
tween the  ages  of  35  and  50  lie  most  of  the  cases. 

(6)  Patients  have  generally  had  acid  dyspepsia  of  the 
intermittent  tj^De  for  from  5  to  30  years.  Seasonal  relation 
of  complaint  is  often  pronounced. 

(c)  Periodicity  of  the  complaint  is  marked. 

{d)    Chronic  appendix  dyspepsia  has  frequently  clouded 


388  CANCER  OF  THE  STOMACH 

the  early  symptomatology.  The  appendix  has  not  rarely 
been  removed  for  early  disability. 

(e)  Epigastric  pain  associated  with  dyspeptic  storms 
occurs  in  practically  100  per  cent,  of  cases.  This  pain  is 
often  subjectively  noted  to  the  right  of  the  mid-line  or  in 
the  right  posterior  scapular  region.  Pain  is  usually  a  dull 
aching,  gnawing  or  sore  feeling.  In  rapidly  developing 
cases  or  where  perforative  exacerbations  have  taken  place, 
pain  may  be  colicky,  cramp-like  or  boring. 

(/)  Pain  time  is  most  frequently  at  its  maximum  when 
the  stomach  is  nearly  or  entirely  empty.  The  ingestion  of 
food  usually  relieves  all  symptoms,  unless  perforation  or 
stenoses  have  supervened.  The  periodic  repetition  of  this 
syndrome  associated  with  ''food-ease"  is  characteristic  of 
nearly  90  per  cent,  of  uncomplicated  ulcers.  Pain  relief 
is  also  obtained  by  alkalies,  vomiting,  rest  or  opiates. 

(g)  Vomiting  occurs  less  frequently  in  duodenal  than  in 
gastric  ulcer  (apart  from  the  extrapyloric  type),  until 
perforation  or  stenosis  takes  place.  When  vomiting  occurs 
it  is  apt  to  be  more  copious  than  in  case  of  the  majority 
of  gastric  ulcers,  inasmuch  as  duodenal  stenoses  tend  to 
more  rapidly  produce  extensive  dilatation  of  the  stomach. 
''Delayed"  vomiting  is  common. 

Qi)  Hemorrhage  (melena  or  hematemesis)  occurs  in 
about  30  per  cent,  of  instances.  Melena  is  a  most  fre- 
quent happening,  but  pronounced  hematemesis  may  occur. 
The  reverse  is  the  rule  in  gastric  ulcer.  The  hemorrhages 
are  generally  intermittent.  Inasmuch  as  duodenal  ulcers 
rarely  become  carcinomatous,  and  because  they  have  a  ten- 
dency to  heal  and  to  be  protected  by  scar  tissue,  persistent 
melena  (even  by  chemical  demonstration)  is  unusual. 

(i)  Eructations,  pyrosis  and  water-brash  are  common,  es- 
pecially 3  to  5  hours  post  ciho  or  at  night  (12  m.  to  1  a  .m.). 


DIFFERENTIAL    DIAGNOSIS  389 

At  these  times  maximum  gastric  acidity  may  be  demon- 
strated. Vomiting,  gastric  lavage  or  alkalies  generally 
bring  about  prompt  relief. 

(j)  Appetite  is  usually  good  except  in  attacks,  but  fear 
of  bringing  on  pain  by  eating  frequently  leads  to  a  poor 
appetite  habit.  Weight  loss  may  be  rapid  during  attacks, 
or  when  pyloric  stenosis  has  supervened.  Bowels  are  not 
infrequently  constipated  during  periods  of  exacerbation. 

2.  Facts  Determined  upon  Examination. — (a)  Patient 
usually  of  plethoric  type  unless  starved  by  diet,  recent 
hemorrhage  or  stenosis.  Body  nourishment  generally 
good;  toxic  evidences  or  cachexia  absent  in  majority  of 
instances. 

(&)  Hemoglobin  averages  80  per  cent,  or  above  in  un- 
complicated cases. 

(c)  Epigastric  tenderness  may  be  lacking.  There  is  no 
typical  point  of  tenderness  in  duodenal  ulcer,  but  usually 
spasm  of  the  right  rectus  muscle  may  be  elicited  on  both 
superficial  and  deep  palpation.  When  recent  or  protected 
perforation  results  in  peritoneal  involvement,  then  local- 
ized tenderness  of  varying  grades  may  be  demonstrated. 
Occasionally  tumor-like,  tender  ridges  may  be  present 
where  much  callous  has  developed  or  adhesions  have 
formed. 

(d)  Dilated,  splashy  stomach  may  be  outlined  even 
without  air  inflation.  This  is  common  where  stenoses 
have  occurred.  Visible  peristalsis  (Kussmaul  type)  is 
not  uncommon  where  marked  stenosis  at  the  pylorus  has 
developed  and  where  the  abdominal  parietes  is  thin. 

3.  Facts  Obtained  upon  Roentgen  Examination. — Upon 
fluoroscopic  examination,  uncomplicated  ulcers  frequently 
return  nothing  of  definite  diagnostic  value.  Evidence 
of  pyloric  spasm  associated  with  hyperperistalsis  are  not 


390  CANCER  OF  THE  STOMACH 

infrequently  seen.  Such  conditions,  however,  are  not 
typical  of  duodenal  ulcer,  even  though  frequently  they  may 
be  associated  with  it.  Local  areas  of  tenderness  are  some- 
times delimited  at  the  pylorus,  or  over  the  duodenum  itself. 
If  they  are  persistent  after  the  hypodermatic  administra- 
tion of  atropine  sulphate,  and  the  clinical  history  is  that 
suggesting  duodenal  ulcer,  these  areas  of  tenderness  are  not 
without  certain  relative  diagnostic  significance. 

Plate  or  film  examination  in  instances  of  duodenal  ulcer 
may  readily  demonstrate  6-hour  retention  of  the  opaque 
meal  and  over-vigorous  peristalsis. 

If  the  duodenal  ulcer  is  of  the  complicated  type  {viz., 
has  exuberant  callus,  perforation,  adhesions,  or  is  large 
enough  to  form  a  crater) ,  plate  or  screen  examination  may 
reveal  malformations  of  the  duodenum,  fixture  of  the 
duodenum  by  adhesions,  various  grades  of  obstruction, 
or  even  fistulas. 

It  is  well  in  suspected  cases  of  calloused  ulcer  of  the 
duodenum  to  make  plates  with  the  patient  not  only  in 
the  dorsal  and  prone  positions,  but  after  he  has  been  placed 
in  the  left  or  right  lateral  positions.  By  this  maneuver 
one  not  infrequently  demonstrates  malformations  of  the 
hulbus  duodeni. 

Sometimes  the  degree  of  obstruction  at  the  pylorus  and 
the  deformity  of  the  duodenum  may  readily  suggest  some 
anomaly  at  the  pyloric  end  of  the  stomach,  on  account  of 
the  abrupt  termination  of  the  stomach  lumen  or  irregulari- 
ties in  its  pyloric  outline.  In  such  instances  at  laparotomy, 
one  may  find  extensive  adhesions,  perforation  or  a  duodenal 
ulcer  which  has  become  cancerous  on  the  gastric  side. 

The  comparative  worth  of  the  different  diagnostic  points 
in  gastric  and  duodenal  ulcer  and  gastric  cancer  is 
further  emphasized  in  Table  37. 


DIFFERENTIAL   DIAGNOSIS 


391 


Table  S: 


I>Jature  of  the  disease 

Clinical 

symptoms 
and  signs 

Carcinoma 

Peptic  ulcer 
(gastric  or 
duodenal) 

Peripyloric            Gastric 
adhesions               atony 

Extragastric 
tumor  pressing 

on  pylorus 
(liver-pancreas) 

Average  age. 

i 

45 

40-50 

40-50         ;  Often    young 
adult. 

50 

Sex. 

Males.  + 

Males,  -t- 

Females.  -1-         Females.  -|- 

Females  ? 

Onset. 

Often     prev. 

Intermittent 

Cholecystitis,      Gradual. 

Progressive. 

idcer   type; 

dyspepsia  of 

gaU-stones, 

dyspepsia, 

ulcer  type. 

colics,    jaun- 

may be  con- 

dice. 

tinuous  and 

progress. 

Pain. 

Early,  usually 
on  empty 
stom. ;   late, 
constant. 

1-5  hours  p.c. 

Worse      soon  '  On  full  stom- 
p.c.  orirreg-       ach. 
ularly. 

■ 

Irregular. 

Vomiting. 

DaUy.    Often 

Frequent. 

Frequent,          Irregular  some- 

Irregular,  reten- 

ret.     vomit 

Often      ret. 

may      show      times,    reten- 

tion      type 

of        rancid 

type;  yeasty 

retention.       ;    tion  type  sour 

often,         odor 

type. 

odor. 

or  yeasty. 

yeasty  or  sour. 

Hemateme- 

In  from   15- 

In   from   20- 

Rare. 

Absent. 

Rare. 

sisor 

25  per  cent. 

40  per  cent. 

melena. 

"Weight  loss. 

Pronounced. 

Intermittent. 

May  be  absent 

Intermittent. 

May  be  marked. 

Test-meal. 

12-lir.      ret.; 

12     hr.     ret. 

12     hr.     ret. 

Intermittent 

12-hr.  retention 

low   or   abs. 

Free        Hcl 

variable;             12    hr.    ret. 

free  Hcl    may 

free        Hcl; 

averages   40 

free          Hcl      Hcl  present 

be      absent, 

lactic    acid; 

altered      bl. 

may           be       yeasts     and 

lactic         acid 

altered    bl.; 

variable; 

normal;               sarcinse  may 

may  be    pres- 

increased 

yeasts     and 

yeasts     and      be  present. 

ent,      Oppler- 

soluble  albu- 

sarcinae may 

sarcinse  may 

Boas       baciUi 

min;  Oppler- 

be  abundant. 

be  present. 

rare.     Altered 

Boaa  baciUi; 

blood  rare. 

mitotic  cells 

(?) 

Stool. 

Altered       bl. 

Intermittent 

-lltered  blood    Altered  blood 

Altered  blood 

in     89     per 

presence    of 

rare. 

absent. 

variable. 

cent.      con- 

altered blood 

stantly;  Op- 

yeasts     and 

pler-Boas 

sarcinse. 

bacilli        60 

per  cent. 

Tumor. 

In  65-75  per 

Infrequent. 

Infrequent.        Absent. 

May    be  pres- 

cent. 

ent. 

Radiogram. 

Filling  defect 

Ret.     6  hrs.; 

Malformed 

DUated  stom- 

Retention       6 

pars  pylorica; 

may  be  cra- 

bulbus duo- 

ach,    poor 

hr.      variable. 

ret.  6  lirs. 

ter    ulcer, 

deni,  ret.    6 

peristalsis;  6 

May  be  filling 

constriction 

hrs.,  may  be     hr.  ret.,  vari- 

defect   at   py- 

or  irregular 

irregular  py-       able. 

lorus  but  may 

pyl.  outline. 

lorus;  dilated 

be  shown  to  be 

dilated  stom. 

stomach. 

extra     gastric 
on  pressure. 

Metastases. 

The  rule. 

Absent. 

Absent.             '  Absent. 

May  occur. 

Malignant  Pyloric  Stenosis  and  its  Differential  Diagnosis  (Author). 


392 


CANCER    OF    THE    STOMACH 


Not  infrequently  certain  lesions  of  the  esophagus  or 
of  structures  in  the  thorax  are  confused  with  gastric 
cancer  at  or  near  the  cardia.  Table  38  summarizes  the 
essential  differential  points  in  the  diagnosis  of  these 
ailments. 

Table  38 


Nature  of  disease 

Clinical 

symptoms 

Carcinoma 

Car.  of 
esophagus 

Cicatricial 

Cardio- 
spasm 

Esopha- 

Thoracic 

and  signs 

at  or  near 
cardia 

stenosis  of 
esophagus 

geal  diver- 
ticulum 

tumor- 
aneurysm 

Average  age 

45 

45 

Young 
adult. 

Young 
adult. 

45 

45 

Sex. 

Male.  + 

Male.  + 

? 

Female,  -f 

Male.  -1- 

? 

Onset. 

Prev.  ulcer 

Gradual. 

Ulcer     his. 

Sudden, 

Gradual. 

Usually 

or  gradual. 

or    corro- 
sives. 

rarely 
gradual  or 
intermit- 
tent. 

gradual. 

Dysphagia . 

Intermit- 

Usually 

Progressive 

Often      in- 

Progressive. 

Progressive. 

tent        or 

constant 

and  mark- 

termittent. 

progres- 

and pro- 

ed. 

sive. 

gressive. 

Pain. 

Soon   after 

During 

During 

May  be  ab- 

During deg- 

During  deg- 

swallowing. 

swallowing 
usually. 

swallowing. 

sent  while 
eating. 

lutition  , 
but     may 
be  absent. 

lutition. 

Vomiting  or 

Fairly  con- 

Constant 

Constant 

Soon    after 

Soon      p.c. 

Soon  p.c. 

regurgita- 

stant soon 

during    or 

p.c. 

or     many 

or    hours 

tion. 

p.c. 

soon  after 
eating. 

hours  after 
eating. 

after. 

Weight  loss. 

Progressive. 

Progressive. 

Progressive 

Intermit- 

Little early, 

Progressive 

in        late 

tent,  may 

rapid  late. 

but  rarely 

stages. 

be  marked 
late. 

rapid. 

Cachexia. 

Pronounced. 

Pronounced. 

Emacia- 

Usually not 

Rarely 

Not  marked 

tion. 

marked. 

marked. 

until  late. 

Hemor- 

Frequent. 

Frequent. 

Absent. 

Absent. 

Absent. 

Rare. 

rhage. 

Test-meal. 

Low     acid, 

Food        as 

Food        as 

Food        as 

Often     ret. 

Often     acid 

blood,  Op- 

eaten. 

eaten. 

eaten, 

food  rests. 

stomach 

pler-Boas 

blood  pres. 

mucus 

much 

juice;  may 

bacilli 

"cancer 

often   ret. 

mucus. 

be     reten- 

"cancer 

cells." 

food  rests. 

tion. 

cells." 

Stool. 

Altered  bl. 

Alt.  bl. 

No  blood. 

No  blood. 

No  blood. 

Rarely 
blood. 

Esophago- 

Tumor     at 

Tumor     in 

Cicatrix  in 

May        be 

Opening  to 

Prssure  on 

scope. 

cardia. 

esopha- 

esopha- 

negative 

sac     may 

oesopha- 

gus. 

gus. 

or  dilated 
esophagus, 
small  car- 
diac    ori- 
fice. 

be  seen. 

gus  locally. 

DIFFERENTIAL    DIAGNOSIS 

Table  38. — Continued 


393 


Nature  of  the  disease 

Clinical 

symptoms 

Carcinoma 

Car.  of 
esophagus 

Cicatricial           ^     j- 
stenosis  of          9^^"^'°' 

Esophageal 

Thoracic 

and  signs 

at  or  near 

diver- 

tumor- 

oardia 

esophagus           ^P'*^^^ 

ticulum 

aneurysm 

Radiogram. 

Opaque 

Obst.       to 

Obst.        to     Usually  dif- 

Dilated 

Rarely    op. 

meal  rests 

opaque 

opaque        ;     fuse    dila- 

esophagus 

meal  rests; 

in  esopha- 

meal, local 

meal;    de-  '.     tation     of 

^   or  local  sac- 

local stric- 

gus;     fill- 

dilatation 

formity  of       esophagus 

culation. 

ture  of 

ing  defect 

of  esoph.; 

esopha-            tapering 

esophagus, 

at  cardia. 

irregular 

gus.                   cardiac 

tumor      or 

lumen  out- 

.    end. 

aneurysm. 

line. 

Duration. 

3  mo.-4  yr. 

Rarely 
more  than 
2  years 

May        be 
many  yrs. 

Many  yrs. 

Many  yrs . 

Varies. 

Tumor. 

Late  in  pit . 

None. 

None. 

None. 

Local  in  tho- 
rax   some- 
times. 

Local         at 
times. 

Metastases. 

Occur. 

Rare. 

None. 

None. 

None. 

None. 

Table  of  Differential  Diagnosis  where  Cancer  Involves  Cardiac  Orifice. — 
(Author. ) 

Gall-bladder  Disease. — Certain  cases  of  chronic  chole- 
cystitis or  cholecystitis  with  cholelithiasis  are  associated 
with  gastric  achylia,  pancreatic  inefficiency  and  deficient 
function  on  the  part  of  the  liver.  Not  infrequently  anemia 
is  present  and  marked  alterations  of  the  biliary  tract  may 
occur  without  jaundice.  Loss  of  flesh,  diarrhoea,  vomiting 
and  epigastric  pain  may  produce  a  symptom-complex 
which  is  difficult  to  distinguish  from  gastric  malignancy. 
In  the  majority  of  these  cases,  the  essential  guide  to  the  diag- 
nosis is  a  careful  anamnesis,  including  particular  inquir>^ 
into  the  earlier  years  of  the  patient's  dyspeptic  ailment. 
One  not  infrequently  learns  by  such  inquiry  that  the 
disease  is  more  common  in  females,  that  there  has  been 
antecedent  typhoid  fever  or  malaria,  that  the  earlier 
dyspeptic  history  is  not  the  type  which  we  associate  clini- 
cally with  chronic  peptic  ulcer;  that  obstruction  has  arisen 
late,  or  is  entirely  absent,  and  that  certain  acute  attacks 
of  indigestion  have  been  associated  with  biliary  symptoms, 


394  CANCER    OF    THE    STOMACH 

namely,  slight  jaundice,  gaseous  abdominal  distension, 
perhaps  vomiting  of  bile,  acute  colic  of  a  passing  stone, 
irregular  pain  usually  without  definite  relation  to  food 
intake,  and  not  unusually  transitory  rises  in  temperature. 
Gastric  analysis  may  show  some  retention  of  the  12-hour 
type.  Retained  contents  are  rarely  of  an  obnoxious  odor, 
and  but  infrequently  contain  lactic  acid,  altered  blood  or 
bacilli  of  the  Oppler-Boas  group.  Free  hydrochloric  acid 
may  be  absent  or  very  low,  but  is  not  so  uniformly  decreased 
as  it  is  in  gastric  cancer.  Stools  may  be  diarrhoeic,  they 
rarely  contain  blood  or  long  acid-fast  bacilli.  The  x-ray 
examination  may  show  6-hour  retention  of  the  opaque 
meal,  dilated  stomach,  deficient  peristaltic  activity,  and  at 
times  irregularities  toward  the  pylorus.  In  these  cases, 
however,  filling  defects  of  the  gastric  lumen  with  irregular 
outline,  which  outline  is  indistinct,  are  uniformly  uncom- 
mon. Sometimes  the  screen  or  plate  reveals  gall-stones,  or 
upon  fluoroscopic  examination  one  can  fully  delimit  the 
boundaries  of  the  pyloric  channel  and  show  that  such  are 
of  normal  contour. 

Cancer  of  the  Gall-tract. — Malignant  disease  of  the 
bihary  passages,  particularly  of  the  gall-bladder,  is  asso- 
ciated with  a  history  of  cholecystitis  or  the  presence  of 
gall-stones  in  from  18  to  40  per  cent,  of  cases.  In  such 
patients  there  is  commonly  an  extensive  precarcinomatous 
history  of  gall-bladder  disease.  The  patient  may  even 
have  passed  gall-stones.  The  antecedent  dyspepsia  has 
been  of  irregular  occurrence,  and  has  not  rarely  been 
associated  with  jaundice  or  fever.  At  the  time  that  the 
patient  comes  under  observation,  jaundice  is  not  an  un- 
common finding. 

Cachexia,  associated  with  clinical  evidence  of  pyloric 
obstruction,  or  the  presence  of  an  epigastric  mass,  may 


DIFFEEEXTIAL    DIAGXOSIS  395 

render  it  difficult  to  exclude  a  neoplasm  involving  the 
stomach.  In  fact,  the  stomach  is  not  rarely  involved  by 
contiguity  in  these  cases.  Cachexia  is  not,  as  a  rule,  so 
pronounced  as  in  cases  of  gastric  cancer.  Vomiting  is  not 
so  constant  or  copious  as  in  gastric  malignancy.  Free 
hydrochloric  acid  may  be  present  in  gastric  extracts,  and 
at  times,  though  infrequently,  lactic  acid,  altered  blood  and 
Oppler-Boas  bacilli  may  be  found.  Blood  is  rarely  a 
constant  finding  in  the  properly  prepared  stool.  The 
abdominal  tumor  is  usually  well  to  the  right,  in  the  mid- 
line, or  beneath  the  edge  of  the  ribs.  It  may  move  up  and 
down  upon  respiration,  but  rarely  changes  position  when 
the  stomach  or  colon  is  inflated.  The  tumor  cannot  be 
moved  during  palpation,  and  can  rarely  be  held  down  by  the 
hands  while  the  patient  is  in  expiration.  These  tumors 
are  apt  to  be  of  less  irregular  form  than  are  the  tumors  of 
gastric  cancer.  They  are  apt  to  be  more  tender  upon 
palpation. 

^Metastases  develop  more  slowly  than  in  the  case  of 
gastric  cancer,  particularly  metastasis  to  the  pelvis,  navel 
and  left  supraclavicular  space.  Ascites  may  develop  much 
earUer  than  where  the  neoplasm  involves  the  stomach,  and 
the  accumulation  of  ascitic  fluid  is  likely  to  be  of  much 
greater  quantity  than  in  the  average  instance  of  pyloric 
cancer. 

Roentgen  examination  may  show  at  once  that  the  tumor 
is  extragastric.  While  not  infrequently  adhesions  rapidly 
develop  between  the  diseased  gaU-tract  and  the  stomach,  in 
many  instances  the  pylorus  remains  free  and  can  be  pushed 
away  from  the  gall-tract  tumor  and  shown  to  be  of  regular 
outline.  There  are  some  cases,  however,  in  which  extensive 
adhesions  about  the  gall-bladder  and  the  head  of  the 
pancreas  may  immobihze  the  pyloric  end  of  the  stomach, 


396  CA^XER  OF  the  stomach 

and  even  give  the  appearance  Roentgenographically  of  a 
canalized  tumor  involving  the  pylorus  and  antrum. 

Tumors  of  the  liver  are  of  comparative  rarity.  The 
left  lobe  of  the  liver  is  apt  to  be  the  seat  of  the  disease. 
The  early  history  of  the  infection  is  rarely  that  of  a  long- 
continued  dyspepsia.  Jaundice  may  appear  early.  Ca- 
chexia is  a  comparatively  late  manifestation  of  the  disease. 
Persistent  vomiting  is  relatively  uncommon.  Weight  loss 
may  be  of  extremely  gradual  onset,  and  may  not  be  as- 
sociated with  marked  evidences  of  systemic  cancerous 
intoxication.  Anemia  may  be  marked.  Xot  infrequently 
the  TTassermann  reaction  is  positive,  owing  to  the  fact  that 
primary  tumors  of  the  liver  are  not  uncommonly  syphiUtie. 
Additional  blood  examination  may  show  eosinophilia  if 
the  liver  tumor  is  of  parasitic  origin  (echinococcus) .  In 
the  early  stages  of  the  disease,  alteration  in  gastric  empty- 
ing power  is  uncommon.  Free  hydrochloric  acid  is  apt 
to  be  normal  and  not  diminished  or  absent  until  systemic 
cancer  poisoning  occurs.  The  stools  rarely  show  the 
presence  of  '^ occult"  blood.  Diarrhoea  may  develop, 
and  microscopic  examination  but  infrequently  shows  the 
presence  of  long,  acid-fast  bacilli.  A  chemical  examina- 
tion of  the  stool  may  show  the  absence  of  hydrobilirubin. 

The  abdominal  tumor  usually  lies  high  in  the  epigastrium. 
It  is  rarely  localized  definitely.  It  is  not  usually  so  tender 
as  is  a  neoplasm  involving  the  stomach.  It  cannot  be 
moved  freely  upon  palpation.  It  moves  with  respira- 
tion. Secondary  metastases  are  rare.  A-ray  examination 
usually  enables  one  to  demonstrate  that  the  tumor  is 
extragastric,  insomuch  as  an  apparent  filling  defect  in  the 
stomach  will  disappear  upon  change  of  position  of  the 
patient  or  upon  one's  moving  the  stomach. 


DIFFERENTIAL    DIAGNOSIS  397 

Disease  of  the  Pancreas. — Instances  of  chronic  inter- 
stitial pancreatitis,  associated  with  enlargement  of  the  gland, 
dyspepsia  and  cachexia,  are  not  uncommonly  confused 
with  gastric  cancer.  The  following  case  illustrates  this 
type  of  ailment. 

Chronic  Interstitial  Pancreatitis;  Emaciation  and  Epigastric 

Tumor: 
Mrs.  M.  B.- — Age  41,  American,  housewife. 

Family  History. — Negative. 

Personal  History. — Typhoid  fever  at  age  of  20.  Recently 
had  laparotomy  performed  for  cholecystitis  and  perichole- 
cystitis. At  laparotomy  the  pancreas  was  found  to  be 
3  times  normal  size,  w^as  hard  and  nodular. 

Comes  on  account  of  vomiting,  weight  loss,  abdominal 
distress,  and  diarrhoea. 

Duration  of  Disease. — ^Twenty  years  off  and  on;  has  had 
several  acute  attacks  of  dyspepsia;  characterized  by  abdom- 
inal pain,  vomiting,  chilly  sensations  and  jaundice. 

At  present  has  mid-epigastric  distress  constantly;  the 
feeling  is  of  ^'soreness  and  weakness;"  it  is  vaguely  trans- 
mitted to  the  back;  it  is  only  relieved  by  opiates.  Vomiting 
of  food  and  foul-tasting,  green  liquid  occurs  daily  and  is 
brought  on  by  food  intake.  Belching,  water-brash  and 
eructations  are  nearly  constant. 

Bowels.- — Diarrhoea  for  6  months;  stools  are  w^atery, 
small  in  amount,  contain  undigested  food  and  have  a  dis- 
gusting, penetrating  odor. 

Weight. — Normal  100  pounds;  one  year  ago  96  pounds;  6 
months  ago  88  pounds;  present  55  pounds. 

Examination. — Thin,  cachectic,  bed-ridden  female,  afeb- 
rile; constantly  belches  gas  and  raises  small  quantity  of 
watery  fluid. 

Throat. — Infected  tonsils. 

Thorax. — Small  heart,  with  weak  muscle  sounds. 

Abdomen. — Stomach  splashy  below  navel;  slight  Kuss- 
maul  peristalsis  seen;  areas  of  tenderness  over  gall-bladder 
region  and  just  above  navel.  In  low  epigastrium  is  a 
tender,  nodular,  sausage-shaped  mass,  slightly  movable 
on  palpation,  but  not  upon  inflation  of  the  stomach. 

Rectal  Examination. — Negative. 


398  CANCER  OF  THE  STOMACH 

Laboratory  Findings: 

Blood.— Rg.,  60  per  cent.;  r.b.c,  3,900,000;  w.b.c, 
7,000. 

Urine. — Few  hyaline  casts. 

Stools. — Thin,  watery,  greenish  brown;  much  undigested 
vegetable  and  meat;  microscopically  enormous  numbers  of 
motile  and  non-motile  rods,  numerous  yeasts  and  cocci. 

Chemical. — Alkaline  reaction;  altered  blood,  trace;  tryp- 
sin absent;  amylase  over  600  units  (in  normal  range). 

Test-meal. — Contents  of  stomach  greenish-yellow.  No 
12-hour  retention.  Total  acidity,  0;  free  Hcl.,  0;  lactic 
acid,  0;  altered  blood,  0;  Wolff,  0. 

Microscopically. — Few  yeasts  and  small  type  sarcinse 
are  seen. 

Roentgen  Examination. — Markedly  ptosed  stomach  of 
fish-hook  form;  atonic;  pylorus  and  antrum  well  visuahzed, 
duodenum  seems  regular.  Epigastric  tumor  is  seen  to  lie 
3  f.b.  above  lesser  ciu^^ature  of  stomach. 

Wassermann. — Negative. 

Laparotomy. — ^Large,  hard  nodular  pancreas;  chronic 
cholecystitis  and  pericholecystitis. 

Pathology. — Tissue  (gland)  inflammatory. 

After  Course. — Patient  alive  after  nearly  3  years;  weighs 
99  pounds;  still  has  epigastric  nodule. 

Important  differential  points  are  summarized  in  Table 
39.  Emphasis  is  to  be  especially  placed  upon  the  anam- 
nesis of  the  precachectic  stage.  This  usually  exhibits 
symptoms  clinically  referable  to  gall-tract  malfunction. 
Test-meal  findings  are  but  rarely  characteristic  of  gastric 
cancer  at  a  stage  when  epigastric  tumor  can  be  pal- 
pated. While  free  hydrochloric  acid  may  be  low  or  ab- 
sent, 12-hour  retention,  altered  blood,  lactic  acid,  positive 
Wolff -Junghans'  test,  increase  in  the  f ormol  index,  or  bacilli 
of  the  Oppler-Boas  type  are  commonly  absent  or  irregularly 
found.  The  abdominal  tumor  is  not  generally  movable 
upon  gastric  or  colon  inflation.  The  stools  rarely  ex- 
hibit altered  blood.     Tests  for  pancreatic  ferments  usu- 


DIFFERENTIAL   DIAGNOSIS 


399 


ally  reveal  absence  or  diminution  of  amylase  or  trypsin,  or 
both.  Roentgen  examination  usually  shows  regular  gastric 
outline,  with  the  stomach  perhaps  at  a  distance  from  the 
palpable  abdominal  tumor. 


Table  39 


Nature  of  the  disease 

Signs  and 

Gastric 

Retroperi- 
toneal 
tumor 

symptoms 

cancer 

Tumor  of 

Tumor  of 

Tumor  of 

Tumor  of 

(body  or 
fundus) 

liver 

pancreas 

colon 

kidney 

Age. 

45 

40 

Variable. 

40 

35 

Variable. 

Sex. 

Males.  + 

Variable. 

Women? 

Males? 

Males? 

Variable. 

Onset. 

Previous 

Gradual 

Gradual 

Gradual 

Gradual; 

Gradual 

ulcer   his- 

and pro- 

and prog- 

and  pro- 

may have 

and      pro- 

tory      or 

gressive. 

gressive; 

gressive 

early    he- 

gressive. 

primary 

trauma? 

acute  with 

maturia. 

progres- 

obstr. 

sive    dys- 

pepsia. 

Pain. 

Pres.  in  95 

Indefinite. 

Rarely 

Intermit- 

Indefinite, 

Indefinite. 

per  cent. 

marked. 

tent    usu- 
ally; may 
be       con- 
stant. 

sometimes 
colics. 

Vomiting. 

Common 

Irregular; 

Irregular; 

Rarely 

Infrequent. 

Irregular; 

and    pro- 

may occur 

may  occur 

early. 

may  occur 

gressive. 

from  pres- 
sure. 

from  pres- 
sure. 

from  pres- 
sure. 

Weight  loss. 

Constant 

Progres- 

Irregular. 

Constant. 

Constant 

Constant 

and     pro- 

sive. 

as  a  rule. 

but    grad- 

gressive. 

ual. 

Cachexia. 

Pronounced 

Pronounced 
late. 

Variable . 

May        be 
marked. 

Often  pro- 
nounced. 

Present. 

Appetite. 

Poor. 

Variable . 

Variable . 

Variable . 

Variable . 

Variable. 

Bowels. 

Constipa- 

Constipa- 

Diarrhoea 

Obstipation 

May        be 

May          be 

tion      the 

tion  fre- 

not      un- 

later diar- 

normal. 

normal. 

rule. 

quent. 

common. 

rhoea. 

Bleeding. 

Hemate- 
mesis     or 
melena  15- 
25         per 
cent. 

Melena    at 
times. 

Absent. 

Common, 
especially 
late. 

Absent. 

Absent. 

Urine. 

Often  nega- 

Often nega- 

Often nega- 

Often nega- 

Local     he- 

Often nega- 

tive. 

tive. 

tive. 

tive. 

maturia  in 
about    60 
per  cent. 

tive. 

Cystoscopic 

Negative. 

Negative . 

Negative. 

Negative. 

Blood       or 

Negative. 

and  pyelo- 

pus    from 

gram. 

1     ureter; 
deformed 
pelvis    on 
collargol 
injection. 

Table  continued  on  page  400 


400 


CANCER    OF   THE    STOMACH 


Table  39.— Continued 


Nature  of  the  disease 

Signs  and 
symptoms 

Gastric 

cancer 

(body  or 

fundus) 

Tumor  of 
liver 

! 

Tumor  of 
pancreas 

Tumor  of 
colon 

Tumor  of 
kidney 

Retroperi- 
toneal 
tumor 

Test-meal. 

Low  or  ab- 
sent    free 

Hcl      may 
be    abst. ; 

Hcl       may 
be  low  or 

Hcl      often 
low      but 

Hcl      may 
be  low  to 

Hcl  usually 
low;  12  hr. 

Hcl;       12 

12  hr.  ret. 

normal;  12 

may       be 

normal; 

ret.      vari- 

hr.     ret.; 
Oppler- 
Boas    ba- 
cilli; lactic 
acid;     al- 

var.; rare- 
ly Oppler- 
Boas    ba- 
cilli        or 
lactic  acid 

hr.       ret. 
variable ; 
Oppler- 
Boas  bac- 
illi, lactic 

normal;  in- 
freq.  12  hr. 
ret. ;  lactic 
acid,      al. 
blood     or 

12  hr.  ret. 
rare,  lactic 
and      alt. 
blood, 
Oppler- 

able,  lactic 
acid,  alter- 
ed     blood 
or  Oppler- 
Boas      ba- 

tered 

Wolff  test 

acid        or 

Oppler- 

Boas    ba- 

cilli    infre- 

blood; 

in     30-50 

altered 

Boas    un- 

cUli   very 

quent. 

Wolff  test 

per  cent. 

blood  rare. 

common. 

rare. 

Stool. 

in  80  per 
cent. 
Altered 

Altered 

Altered 

Altered 

Altered 

Altered 

blood    89 

blood  un- 

blood un- 

blood    in 

blood  rare. 

blood  rare. 

per  cent. 

common. 

common. 

70-90  per 
cent. 

Abdominal 

In  about  60 

In  from  GO- 

In    50    per 

In      30-50 

In    75    per 

In        70-90 

tumor. 

per    cent., 

GO         per 

cent. 

per    cent. 

cent,  may 

per  cent. 

often 

cent. 

moves 

moves  on 

move     on 

usually 

movable. 

moves 
with      res- 
piration. 

with      res- 
piration or 

with  stom- 
ach. 

respiration 
or  on  colon 
inflation. 

respir. 

fixed. 

Radiogram. 

12       hours 

12       hours 

12       hours 

12       hours 

12       hours 

12       hours 

retention 

ret.       un- 

ret.   var. ; 

stom.  ret. 

stom.  ret. 

ret.     vari- 

not      un- 

common; 

palpation 

var.  tumor 

variable ; 

able  tumor 

common.  ; 

palpation; 

on  fluoro- 

mass    ex- 

tumor  ex- 

mass  extra- 

filling  de- 
fects. 

on  fluoro- 
scopic 
exam, 
shows 
mass  to  be 
extra- 
gastric. 

scopy 
shows 
tumor    to 
be    extra- 
gastric  . 

tragastric; 
colon 
exam, 
shows  ret. 
of  opaque 
meal    and 
filling  de- 
fects      of 
bowel. 

tragastric. 

gastric. 

Ascites. 

Occurs  late. 

May  occur 

Uncommon. 

Very      un- 

Very     un- 

May occur. 

Jaundice. 

Late,     due 
to  metas- 
tases. 

early. 
May        be 
early   and 
constant. 

Variable 
according- 
ly as  gall- 
ducts    are 

obstructed. 

common. 
Rare. 

common. 
Rare. 

Infrequent. 

Differentiation  of   Gastric   Cancer  of  Body  or  Fundus  from  Tumors  in 
Adjacent  Structures. — (Author.) 


Cyst  of  the  pancreas  is  of  infrequent  occurrence.     The 
history  should  be  searched  for  facts  relative  to  gall-stones, 


DIFFERENTIAL   DIAGNOSIS  401 

trauma  or  perforating  peptic  ulcer.  Pancreatic  cysts 
often  attain  great  size  without  giving  marked  gastric 
symptoms.  Cachexia  develops  slowh^  The  tumor  can 
generally  be  shown  to  be  distinct  from  the  stomach  by 
air  inflation  of  the  stomach  and  large  bowel.  Gastric 
examination  by  test-meals,  commonly  reveals  free  empty- 
ing power,  normal  free  hydrochloric  acid,  and  absence  of 
altered  blood,  lactic  acid  or  long  acid-fast  bacilli.  The 
stools  may  be  diarrheic ;  they  rarely  exhibit  altered  blood. 
Pancreatic  ferments  may  be  lacking.  Roentgen  exami- 
nation may  demonstrate  that  the  tumor  has  no  connection 
with  the  stomach. 

Abscess  of  the  pancreas  is  commonly  associated  with 
history  of  infection  of  the  gall-tract,  penetrating  ulcer, 
acute  pancreatitis,  or  trauma.  Shock  may  be  marked 
early.  Temperature  and  leucocytes  are  increased.  Vomit- 
ing may  be  uncontrollable,  and  be  bloody  in  kind.  The 
abdominal  tumor  is  rarely  locahzed.  It  is  usually  fixed 
and  tender  upon  palpation.  The  test-meal  findings  are 
variable.  They  may  be  negative  unless  previous  gastric 
ulcer  has  existed.  Stools  rarely  contain  altered  blood, 
but  pancreatic  ferments  rasij  be  lacking.  Glycosuria 
may  be  demonstrated.  Roentgen  examination  shows  the 
tumor  to  be  extragastric,  or  reveals  crater  ulcer  or  mal- 
formations due  to  adhesions.  If  the  abdomen  is  very 
tense,  locaUy,  exploratory  puncture  may  reveal  an  abscess 
cavity  that  has  no  communication  with  a  viscus.  Carmine 
(gr.  v)  administered  by  the  mouth  may  prove  this  lack 
of  a  fistulous  tract. 

Carcinoma  of  the  pancreas  is  generally  secondary  to 
mahgnant  disease  of  the  stomach,  gall-tract  or  fiver. 
The  history  of  the  primary  affection  is  usually  char- 
acteristic and  suggestive.     It  is  impossible  chnically  to 

26 


402  GANCEK  OF  THE  STOMACH 

separate  some  primary  malignant  pancreatic  tumors  from 
gastric  cancers  until  laparotomy  is  performed.  On  ac- 
count of  the  early  invasion  of  the  stomach  wall  the  symp- 
toms of  the  disease  may  closely  mimic  gastric  cancer. 
Tumors  of  the  pancreas  early  become  fixed  or  move  only 
on  respiration,  and  not  upon  gastric  or  colonic  inflation  with 
air.  Diarrhea,  often  prostrating,  may  be  an  early  mani- 
festation. The  stools  rarely  contain  blood,  macroscopically 
or  chemically.  Tryptic  and  amylolytic  digestion  may  be 
reduced  or  lacking.  Roentgen  examination  may  show  that 
the  focus  of  disease  is  extragastric. 

Enlargement  of  the  spleen  may  at  times  present  a  clinical 
picture  that  is  confused  with  cancer  of  the  greater  curvature 
or  fundus  of  the  stomach.  In  splenic  enlargements  the 
anamnesis  usually  discloses  history  of  a  chronic,  general 
infection,  of  malaria,  trauma,  or  of  blood  dyscrasia.  Ab- 
dominal examination  generally  demonstrates  a  tumor  with 
a  well  delimited,  rather  sharp  edge;  the  spleen  ''notches" 
are  recognized;  the  mass  is  smooth  and  moves  on  respiration 
but  not  upon  inflation  of  the  stomach  or  colon.  Blood 
analj^ses  often  establish  a  leukemia.  Secondary  nodules 
are  rare  in  disease  of  the  spleen.  When  such  occur,  they 
are  in  the  blood-forming  organs  or  lymphatics.  The  liver 
may  show  enlargement  nearly  as  great  as  that  of  the  spleen. 
The  test-meal  rarely  exhibits  gastric  retention.  Low  free 
hydrochloric  acid  may  be  observed,  but  organic  acids, 
altered  blood  or  bacilli  of  the  Oppler-Boas  type  are  rarely 
found.  The  stool  contains  blood  chemically  in  almost 
50  per  cent,  of  cases.  Roentgen  examination  may  prove 
that  the  tumor  is  extragastric. 

Tumors  of  the  kidney,  large  bowel,  omentum  and  retro- 
peritoneal tissues  not  infrequently  offer  problems  in  the 


DIFFERENTIAL    DIAGNOSIS  403 

proof  of  their  being  extragastric.  Table  39  summarizes 
the  essential  features  of  their  differentiation. 

Primary  tumors  of  the  small  intestine  are  of  very  un- 
common occurrence.  Their  most  common  location  is  in  the 
first  3  feet  of  the  jejunum  or  the  terminal  3  feet  of  the 
ileum.  They  may  give  rise  to  only  vague  dyspepsia  until 
stenosis  occurs.  On  account  of  the  occurrence  of  colicky 
pains,  this  dyspepsia  is  frequently  mistaken  for  gastric 
ulcer  or  appendicitis  until  diarrhea,  hemorrhage,  emacia- 
tion or  abdominal  tumor  develop.  If  the  jejunum  is 
involved  just  distal  to  the  duodenum,  gastric  contents 
exhibiting  retention  (really  duodenal)  or  low  free  hydro- 
chloric acid  may  be  obtained.  Rarely  are  organic  acids, 
altered  blood  or  Oppler-Boas  bacilli  noted.  Early  tender- 
ness of  the  tumor  is  observed.  The  bowel  proximal  to  it 
is  distended.  The  tumor  shows  little,  if  any,  relation  to 
the  stomach  upon  that  viscus  being  distended  with  air. 
Roentgen  examination  may  show  halting  of  the  opaque 
meal  with  anomaly  in  outline  of  the  bowel  in  the  region  of 
the  tumor.  When  the  ileum  is  the  seat  of  the  disease, 
stenosis  may  be  the  earliest  sign,  apart  from  cachexia. 
This  evidences  itself  by  constipation  (occasionally  bloody 
stools  with  diarrhea),  colicky  abdominal  pains,  tender, 
distended  abdomen  or  irregular  "false  tumors^'  due  to 
accumulations  of  air  and  chyle  in  the  small  intestine. 
Roentgen  examination  may  demonstrate  the  dilated  ileum 
proximal  to  an  alteration  in  outline  of  its  lumen. 

Achylia  gastrica  (primary  or  associated  with  the  anemias 
coincident  to  pernicious  anemia,  Addison's  disease  and 
cardio-renal  malfunction)  not  infrequently  occurs  at  the 
''cancer  age"  and  may,  on  casual  examination,  be  con- 
fused with  gastric  cancer.  The  essential  differential  points 
are  summarized  in  Table  40. 


404 


CANCER    OF    THE    STOMACH 


Table  40 


Nature  of  the  disease 

Clinical 
signs  and 
symptoms 

Gastric 

Achylia 

Pernicious 

Cardio-renal 

Addison's 

cancer 

gastrica 

anemia 

disease 

disease 

Age. 

45 

40 

35 

45 

30 

Sex. 

Males,  -f 

About  equally 
divided. 

Males.  -{- 

Males.  + 

About  equally 
divided, 

Onset. 

Often    malig. 

Gradual    on- 

Slow and  in- 

History of  in- 

Insidious   with 

after  years  of 

set;  may  be 

sidious;  gas- 

fectious  ail- 

progressive 

dyspepsia.  If 

old     history 

tric      symp- 

ment         or 

weakness. 

no  prev.  his- 

of   gastritis. 

toms     often 

cardio-renal 

tory  of  dysp. 

usually     in- 

secondary. 

overstrain. 

prog.       and 

definite  "dys- 

continuous 

spepsia." 

indigestion. 

Pain. 

Present  in  95 

Indefinite  dis- 

Rare    unless 

Rare  or  vague. 

Irregular 

per  cent. 

tress. 

card,  symp- 

Occasionally 

cramps     at 

toms        de- 

abdominal 

times. 

velop. 

"cramps." 

Vomiting . 

Common 
early        and 
late   in   dis- 
ease. 

Irregular. 

Infrequent . 

Irregular. 

Irregular. 

Weight  loss. 

Constant  and 
progressive. 

Variable. 

Variable      or 
intermittent. 

Variable. 

Progressive. 

Cachexia 

Pronounced . 

Rarely 

Not        often 

Infrequent. 

May    be    pro- 

marked. 

pronounced. 

nounced; 
weakness    out 
of  all  propor- 
tion. 

Blood    pres- 

Reduced. 

May    be    re- 

Reduced. 

Increased 

Markedly      re- 

sure. 

duced. 

usually. 

duced. 

Anemia. 

Erythrocytes 

May  be  slight 

Erythrocytes 

Slight  secon- 

May be  mark- 

average 

secondary 

usually    be- 

dary anemia 

ed.         Rarely 

above  3,500,- 

anemia. 

low    2,500,- 

the  rule. 

high          color 

000,         Hg. 

000;  Hg.  re- 

index.        Nu- 

above       60 

latively  high; 

cleated      ery- 

per cent. 

nucleated, 
red     cells, 
variations  in 
size     and 
shape. 

throcytes  may 
be  found. 

Urine. 

Often     nega- 

Often    nega- 

Usually nega- 

Albumin 

May   be   nega- 

tive. 

tive. 

tive  or  mild 
albumin- 
uria. 

casts,  ery- 
throcytes or 
alteration  in 
daily  quant. 
Phenosul- 
phona  ptha- 
leiu  test. 

tive. 

Hemorrhage 

In   from    15- 
25  per  cent. 

Very  rare. 

Very  rare . 

Rare. 

Rare. 

DIFFERENTIAL   DIAGNOSIS 


405 


Table  40. — Continued 


Nature  of  the  disease 

Clinical 

signs  and 
symptoms 

Gastric 
cancer 

Achylia 
gastrica 

Pernicious 
anemia 

Cardio-renal 
disease 

Addison's 
disease 

Test-meal. 

Low  free  Hcl; 

Absent      free 

Low    or    abs. 

Acid  may  be 

Free   Hcl    and 

often  12  hr. 

Hcl;       total 

acidity;  rare- 

normal      or 

total     acidity 

food    reten- 

acidity  low; 

ly  12  hr.  ret. ; 

low,          not 

absent  or  low; 

tention ;  Op- 

12    hr.    ret. 

lactic      acid 

usually    ab- 

12     hr.      ret. 

pler-Boas 

infrequent ; 

rare;  altered 

sent;  12   hr. 

very          rare; 

bacilli  ;lactic 

lactic      acid 

blood    often 

ret.    infre- 

lactic acid  or 

acid;  altered 

and    altered 

in         trace; 

quent. 

altered    blood 

blood. 

blood  rare. 

streptooo(3ci 
abundant; 
Oppler-Boas 
baciUi    very 
rare. 

uncommon. 

Stool. 

Altered  blood 
89  per  cent. 

Infrequent. 

Often  traces. 

Infrequent. 

Variable. 

Bowels. 

Constipation 

Diarrhoea  not 

Diarrhoea  not 

Alternating 

Diarrhoea  not 

the  rule. 

uncommon. 

uncommon. 

diarrhoea 
and    consti- 
pation. 

infrequent. 

Appetite. 

Usually  poor. 

Capricious. 

Variable . 

Often  good. 

Capricious. 

Tempera- 

Infrequent. 

Normal. 

Often    eleva- 

Normal      or 

Frequently  ele- 

ture. 

tions    of    1° 
to  3°  F. 

subnormal. 

vations   of    1° 
to  3°  F. 

Tuberculin 

Negative,  the 

Negative,  the 

Negative,  the 

Negative,  the 

Frequently 

test    (sub- 

rule. 

rule. 

rule. 

rule. 

positive. 

cutaneous')  . 

Radiogram. 

Gastric  reten- 

Rarely      ret.; 

No  retention 

Cardiac 

Gastric     atony 

tion;    filling 

atony,       no 

or  filling  de- 

changes 

marked. 

defects. 

filling       de- 

defects; 

stomach 

fects. 

gastric  atony 

may           be 
normal. 

Abdominal 

In  3  out  of  4 

Absent. 

Absent. 

Absent. 

Absent. 

tumor. 

cases. 

Metastases. 

Common. 

Absent. 

Absent. 

Absent. 

Absent. 

Ascites. 

Not        infre- 
quent ;      late 
in  disease. 

Absent. 

Absent. 

May       occur 
with    per- 
ipheral 
edema. 

Absent. 

Edema. 

Small       amt. 
at  ankles. 

Rare. 

Small  amount 
in     extrem- 
ities. 

Often  marked. 

May  occur 

Differentiation  of  Gastric  Cancer  from  Other  Ailments  Associated  with 
Low  Gastric  Acidity,  Anemia  and  Cachexia. — (Author.) 

Malignant  peritonitis  may  result  from  lymphatic  spread- 
ing of  a  primary  gastric  focus,  cancer  of  the  liver,  the  gall- 
tract,  neoplasm  of  the  bowel  or  the  pelvic  organs.  It 
is  rarely  primary.  Sometimes  the  clinical  picture  pre- 
sented  is   confusing   on   account   of  its   association  with 


406  CANCER  OF  THE  STOMACH 

ascites.  In  its  early  stage  it  not  infrequently  resembles 
tuberculous  peritonitis.  It  is  rarely  febrile,  is  apt  to  be 
less  painful  and  is  not,  as  a  rule,  associated  with  ulcera- 
tions of  the  bowel.  The  various  differential  facts  have 
been  brought  out  in  Table  41. 

Ascites  is  of  not  infrequent  occurrence  in  late  gastric 
cancer.  If  the  symptoms  of  the  primary  disease  have 
been  obscure,  or  have  not  been  inquired  into  clinically, 
the  presence  of  free  intraabdominal  fluid  may  render  the 
diagnosis  difficult.  These  facts  have  also  been  emphasized 
in  Table  41. 

Usually  careful  anamnesis,  examination  of  the  gastric 
extract,  search  for  ''occult"  blood  in  a  properly  pre- 
pared stool,  or  Roentgen  examination  of  the  stomach,  en- 
able one  to  locate  the  stomach  as  the  original  seat  of 
trouble. 

A  study  of  the  ascitic  fluid  is  not  infrequently  of  much 
value  in  the  differentiation  between  malignant,  infectious 
or  benign  abdominal  ailments.  These  facts  have  been 
fully  emphasized  by  Dock.  This  investigator  has  shown 
that  fluid,  obtained  from  the  abdomen  by  puncture,  can 
sometimes  be  demonstrated  to  be  malignant  by  a  careful 
study  of  its  cellular  elements.  These  may  be  obtained  from 
the  aspirated  fluid  by  successive  centrifugalization.  The 
making  of  smears  from  the  precipitate  in  the  tubes,  dry- 
ing them,  fixing  and  staining  with  Unna's  polychrome 
methylene  blue,  Wright's  stain,  or  hematoxyhn  and 
eosin  enable  study  of  the  different  types. 

In  cancer  of  the  stomach,  and  not  infrequently  in  other 
malignant  intraabdominal  diseases,  large,  swollen,  irregu- 
larly shaped  endothelial  cells  may  be  recognized.  These 
show  atypical  mitoses,  the  nuclei  being  frequently  large  or 
of  extremely  bizarre  shapes. 


DIFFERENTIAL    DIAGNOSIS 


407 


Ta.ble  41. 


Nature  of  the  disease 


Signs  and       Gastric  cancer  ! 

symptoms       peritoneal  or    '.      Cancer  of      i    Tuberculous 
hepatic  metas-  j    peritoneum    |      peritonitis 
tases 


Cirrhosis  of 
liver 


Cardio-renal 
disease 


Age. 
Sex. 
Onset. 


Pain. 


Vomiting. 
Weight  loss. 

Cachexia. 

Appetite. 
Bowels. 


Blood  pres- 

siire. 
Jaundice. 
Abdomen. 


Tumor. 


Fluid. 


Test-meal. 


45 

Males.  + 

Prev.  peptic 
ulc.  or  pri- 
mary malig- 
nant gastric 
disease. 

Present  in  95 
per  cent. 

Common  eariy 

or  late. 
Progressive. 


Pronounced. 


Females.  -|- 
Secondary  to 
pelvic         or 
gradual  and 
atypic. 

Colics  may 
occur  early 
or  late. 

Infrequent. 

Progressive. 


Pronounced. 


Young  adults. 
? 

Pulmonary  or 
abdominal 
tuberculosis 
(kidney, 
ovaries  1 . 

Colics  or  ache 
early. 


40 

Males.    + 

Gastritis, 

alcoholic 

excesses. 


Distress  late. 


Not  the  rule.     Variable. 


40 

Males  ? 

Infectious   ex- 
posure    or 
cardio-renal 
overstrain. 

Irregular 
cramps  at 
times. 

Irregular. 


Poor.  I  Poor. 

Constipation        Variable, 
often. 


Progressive 
but         often 
very  gradual. 
Pronounced 

late. 
Capricious. 
Diarrhcea 

variable. 


Marked       in  i  Variable. 
late  stages. 


Sometimes 

late. 
Variable. 
Constipation, 

diarrhoea  at 

times. 


Reduced. 

Late  if  at  all. 

Often  scaphoid 
but  may  be 
distended    in 
flanks  or 

wholly. 

In  3  out  of  4 
cases. 


Reduced. 

Rare. 
Distended 

late. 


Reduced.  May    be    in- 

i    creased. 
Rare.  I  May  occur. 

May  be  early     Tense  or  dis- 

tense  or  dis-       tended. 

tended.  | 


Infrequent. 

Often  good. 

Diarrhoea  and 
constip.  al- 
ternating not 
infrequently. 

Usually  in- 
creased. 

Infrequent. 

Distended. 


Usually      free;  I 
serous  or 

bloody  "can-  i 
cer  cells"    (?).' 

Low  or  absent 
Hcl;  12  hr. 
ret.  lactic 
acid ;  altered 
blood  or  Op- 
pler-Boas  ba- 
cilli. 


Early    multi- 
ple nodules. 


Often  in  loculi 
bloody,  chy- 
lous, or  ser- 
ous; "cancer 
cells"    (?). 

Low  Hcl. 


Numerous 
ridges   often 
above  navel; 
slow    devel- 
opment. 
Serous  or 

cloudy,  many 
small  lympho- 
cytes, bacilli 
rarely  found. 
Often  low 
Hcl. 


Local  enlarge-  Liver  may  en- 
ment  in  right;  large  or  no 
upper  abd.  I  tumor  pres- 
(liver) .  I     ent. 

Serous,  rarely     Serous, 
bloody    but 
may  be  bUe- 
stained. 

Hcl  may  be  Hcl  may  be 
normal.  normal. 


Table  continued  on  page  408. 


408 


CANCER    OF   THE    STOMACH 


Table  41. — Continued 


Nature  of  the  disease 

Signs  and 

Gastric  cancer 

symptoms 

peritoneal  or 

Cancer  of         Tuberculous 

Cirrhosis  of 

Cardio-renal 

hepatic  metas- 

peritoneum        peritonitis 

liver 

disease 

" 

tases 

Stool. 

Altered    blood 

Blood  rare. 

Blood  late. 

Blood       may 

Blood      infre- 

in 89  per  cent. 

occur  late. 

quent. 

Urine. 

May  be  normal. 

May  be    nor- 
mal. 

Albumin  late. 

Albumin  late. 

Large  volumes 
of      albumin 
and     casts 
often     early. 
Phenolsul- 

phonphtha- 

lein  test. 

Radiogram. 

Gastric   reten- 

Usually nega-  >  Usually  nega- 

Negative    or 

Usually  nega- 

tion variable; 

tive,                     tive. 

pressure  de- 

tive. 

filling  defects. 

feet       from 
bver. 

Metastases. 

Common. 

Common     to     Involvement 

Absent. 

Absent. 

serous     sur- 

of   lungs, 

faces  or  belly 

liver,  intes- 

wall.                 '     tines  or  pel- 

vie  organs. 

Edema. 

Late      and 

Late      and    Late      and 

Late  and  not 

May  be  mark- 

limited. 

limited.                limited. 

1 

often  mark- 
ed. 

ed  early. 

Tempera- 

Infrequent 

Infrequent      1  Irregular 

Elevation 

May  be   sub- 

ture. 

increase. 

increase.       !    elevation. 

late. 

normal. 

Differential  Diagnosis  between  Gastric  Cancer  with  INIetastases  to  the 
Peritoneal  or  Portal  System  and  Diseases  Associated  with  Ascites. — (Author.) 

In  tuberculosis,  colorless  or  straw-colored  fluid  is  usually 
obtained.  Its  cellular  constituents  are  few.  A  study  of 
the  cell  forms  reveals  excess  of  small  lymphocytes.  In 
extensive  malignancy,  bloody  ascitic  fluid  may  be  present. 
In  such  instances  red  blood  cells  may  be  found  together 
with  endothelial  cells  showing  atypical  division. 

In  a  few  cases  of  gastric  cancer,  particularly  where  there 
has  been  involvement  of  the  large  lymphatic  channels,  as 
for  example  the  receptaculum  chyli,  or  the  thoracic  duct, 
the  ascitic  fluid  may  be  milk-like  or  creamy.  This  occurred 
in  three  instances  in  our  series.  A  microscopic  study  of  this 
fluid  is  not  infrequently  negative,  with  the  exception  of 
demonstrating  a  large  number  of  lymphocytes  and  fat 
droplets. 


DIFFERENTIAL    DIAGNOSIS  409 

The  Incidence  of  Ascites  in  Gastric  Cancer. — Free  fluid 
is  usually  an  evidence  of  late,  hopelessly  inoperable  gastric 
cancer.  When  free  fluid  is  present  other  signs  of  the 
disease  are  not  lacking.  It  most  commonly  occurs  with 
secondary  involvement  of  the  peritoneum  itself,  the  liver, 
pelvic  organs,  the  ovary,  transverse  colon,  gastrocolic 
omentum  and  pancreas.  In  our  series  of  cases,  ascites  was 
present  in  86  instances  or  9.3  per  cent.  These  were  all 
inoperable  cases,  and  laparotomy  usually  disclosed  exten- 
sive glandular  invasion  wholly  irrespective  of  the  size  or 
position  of  the  local  growth  in  the  stomach. 

Gastric  cancer  secondary  to  malignancy  in  organs  other 
than  the  stomach  occurred  in  sixteen  instances  in  our  series. 
It  was  secondary  to  tumors  of  the  breast,  the  liver,  female 
genitalia,  colon  and  the  pancreas.  Invasion  of  the  stomach 
was  either  by  l}miph-gland  metastases,  or  by  contiguous 
involvement.  Usually  in  these  cases  anamnesis  and  general 
physical  examination  disclosed  a  primary  tumor.  Xot 
rarely  operative  procedures  had  already  been  performed 
upon  the  primary  growth. 

As  we  have  already  mentioned,  it  would  seem  c[uite  neces- 
sary to  differentiate  many  so-called  secondary  gastric  cancers 
from  primary  malignant  processes  wholly  independent  of 
an  extra-gastric  lesion,  to  which  they  are  sometimes  con- 
sidered secondary. 

Syphilis  of  the  Stomach. — Sj^phihs  of  the  stomach  is 
becoming  more  readily  recognized  since  the  perfection  of 
blood-serum  tests  for  lues.  In  the  majorit}'  of  instances  of 
gastric  syphiHs  anamnesis  discloses  an  early  specific  lesion. 
Physical  examination  may  demonstrate  certain  local  or 
general  evidences  of  secondarj'  or  tertiar}^  manifestation  of 
the  disease. 

Before  the   onset   of   a   definite  tumor  growth  in   the 


410  CANCER  OF  THE  STOMACH 

stomach,  the  history  is  not  infrequently  that  which  we 
associate  with  chronic  peptic  ulcer.  Inasmuch  as  ulcera- 
tion of  the  stomach  in  gastric  syphilis  is  apt  to  be  multiple, 
epigastric  pain  and  a  continuance  of  the  dyspepsia,  instead 
of  having  it  occur  at  intervals,  may  be  quite  markedly 
evidenced. 

Gummata  of  the  wall  of  the  stomach  or  extensive  invasion 
of  the  mucous  membrane  may  develop  in  time  in  the  course 
of  the  disease  and  may  be  readily  mistaken  for  cancer.  A 
large  growth  may  press  upon  the  pylorus,  may  produce 
malignant  hour-glass,  bring  about  multiple  tumors  in  the 
stomach,  or,  as  a  result  of  necrosis  of  a  portion  of  these 
tumors,  cause  the  development  of  numerous,  seemingly 
maUgnant  ulcers. 

Whenever  a  case  of  multiple  gastric  tumor  or  multiple 
chronic  gastric  ulcer  is  demonstrated,  the  Wassermann 
test  should  be  made  as  routine.  If  this  test  is  positive,  then 
specific  treatment  should  be  pushed.  This  therapeutic 
differentiation  is  an  important  one.  We  have  seen  large 
multiple  ulcers  of  the  stomach  and  even  gummata  dis- 
appear under  proper  antiluetic  treatment. 

Tuberculosis  of  the  stomach  is  extremely  uncommon. 
While  tubercle  bacilli  are  frequently  swallowed,  they  do  not 
seem  to  retain  their  viability  in  the  presence  of  normal 
gastric  juice.  While  it  is  conceivable  that  initial  trauma 
in  the  gastric  lining  may  furnish  a  lodging  point  for  tubercle 
bacilli,  and  as  a  consequence  ulcer  may  develop,  it  is  more 
than  likely  that  tuberculous  ulcers  or  granulomata  develop 
in  the  gastric  wall  as  a  consequence  of  bacilli  being  carried 
by  the  blood  or  lymphatic  streams. 

Primary  tuberculosis  of  the  stomach  is  of  such  great 
rarity  that  when  a  large  chronic  tuberculous  ulcer  is  found 
in  this  viscus,  search  for  the  primary  focus  of  the  disease 


DIFFERENTIAL    DIAGNOSIS  411 

should  be  made.  It  is  usually  found  in  the  lungs,  kidneys 
or  the  peritoneum.  The  sj^mptoms  of  the  disease  are 
similar  to  those  associated  with  non-tuberculous,  benign 
gastric  ulcer.  The  presence  of  these  ulcer  symptoms  in  an 
individual  with  no  tuberculosis  should  be  sufficient  to 
suggest  proper  diagnosis.  Extreme  emaciation,  the  pres- 
ence of  fever,  abdominal  tenderness  and  the  positive  tuber- 
culin reaction  should  render  recognition  of  the  condition 
apparently  easy  if  the  fact  is  borne  in  mind  that  such  an 
affection  is  likely  to  occur. 

Gastric  granuloma  is  a  rare  ailment  and  is  not  usually 
diagnosed  until  laparotomy  or  at  the  post-mortem  table. 
Interesting  cases  have  been  reported  by  Meyer  and  Hardy. 
A  syphilitic  etiology  not  infrequently  underlies  the  condi- 
tion. Epigastric  pain,  weight  loss,  vomiting,  hemorrhage 
and  sometimes  the  finding  of  a  characteristic  bit  of  tissue  in 
either  the  vomitus  or  the  stools  are  facts  which  are  of  service 
in  diagnosing  the  existence  of  the  disease  in  the  stomach. 

Roentgen  examination  may  reveal  multiple  gastric 
tumors,  a  gastric  outline  of  small  size  and  irregular  form 
or  occasionally  the  actual  e\ddences  of  polypoid  growths.1 

The  importance  in  recognizing  this  condition  is  that  of 
preventing  patients  coming  to  operation  for  a  condition 
which,  of  course,  is  not  curable  surgically. 

Linitis  plastica  or  cirrhosis  of  the  stomach  is  a  disease  in 
which  there  is  an  enormous  fibroid  thickening  of  the  gastric 
wall.  This  is  usually  general,  although  it  appears  in  certain 
cases  to  progress  from  the  pyloric  end  toward  the  cardia. 
This  enormous  thickening  of  the  stomach  wall  results  in  a 
contraction  of  the  stomach  with  the  production  of  a  small 
lumen.  Obstruction  mth  vomiting,  retention,  absent 
hydrochloric  acid,  emaciation,  anemia  are  usually  clinical 
manifestations.     A  full  account  of  this  rather  uncommon 


412  CANCER  OF  THE  STOMACH 

condition  has  been  given  by  Lyle.  Clinically,  the  affec- 
tion is  usually  considered  as  extensive,  scirrhus  cancer 
of  the  stomach,  or  as  sarcoma.  Laparotomy  and  the 
examination  of  sections  of  extirpated  tissue  furnish  the 
only  reliable  differential  points  in  this  disease. 

Sarcoma  of  the  stomach  is  comparatively  rare.  It  was 
present  in  4  cases  in  our  series.  Excellent  analyses  of  this 
condition  have  been  made  by  Clendenning,  Yates  and 
Campbell.  Clinically,  there  is  not  infrequently  a  previous 
history  of  gastric  ulcer.  The  supervening  malignant  period 
is  in  every  way  similar  to  that  of  gastric  cancer.  Hemor- 
rhage is  perhaps  more  common.  Extensive  metastases 
may  occur  early. 

We  have  seen  one  instance  where  invasion  of  the  left 
supraclavicular  lymph  nodes  resulted  in  a  tumor  the  size  of  a 
grape  fruit  2  months  after  the  onset  of  a  gastric  disease 
apparently  malignant,  and  following  upon  a  previous  ulcer. 

Foreign  Bodies  in  the  Stomach. — These  are  of  rare 
occurrence  in  the  human,  but  may  attain  great  size.  There 
is  usually  the  history  of  swallowing  of  such  things  as  nails, 
keys,  hair,  thread  and  the  like.  The  patients  are  not 
infrequently  neurotic  or  of  the  circus  class.  The  foreign 
bodies  may  form  recognizable  abdominal  tumors.  Their 
traumata  may  bring  about  hemorrhage.  Weight  loss  may 
be  constant  on  account  of  obstruction  or  dread  of  pro- 
ducing pain  on  food  ingestion.  There  is  rarely  associated 
with  it  cachexia  coming  from  systemic  poison  as  a  con- 
sequence of  malignant  disease. 

Roentgen  examination  may  definitely  recognize  the 
tumor  as  being  intragastric,  or  demonstrate  metal,  stones 
and  the  like. 

Foreign  Bodies  in  the  Large  Bowel. — ''Bezoar  stones" 
are  uncommon.     They  may  result  from  inspissated  feces, 


DIFFEREXTIAL    DIAGXOSIS  413 

calcareous  deposits,  gall-stones  or  parasites.  They  not  in- 
frequently occur  in  individuals  who  have  worked  on  farms 
or  have  been  associated  with  cattle  and  horses.  The 
gastric  findings  are  rarely  confused  with  those  of  cancer 
of  the  stomach.  ITnless  there  is  obstruction,  emaciation 
and  cachexia  are  uncommon.  The  abdominal  tumor  is 
at^-pically  situated  and  in  the  large  majority  of  cases 
below  the  navel.  Roentgen  examination  may  definitely 
prove  that  the  tumor  is  extragastric.  Sometimes  its 
character  may  be  determined  by  plate  or  screen  examina- 
tion.    The  following  history-  is  suggestive. 

Tumor  {71  Left  Hy-pochondrium;  Constipation;  Bezoar  Stone. 

Dr.  J.  C. — Age  46,  American,  veterinarian. 

Family  History . — Unimp ort ant . 

Personal  History. — Several  severe  attacks  of  la  grippe. 
Intermittent  dyspepsia  of  type.  clinicaU}^^,  duodenal  tilcer 
for  6  to  10  years. 

Present  Trouble. — Gradually  developing  constipation  for 
past  l}i  years;  at  present  has  marked  obstipation;  asso- 
ciated with  tills  are  abdominal  pains  (usually  about  navel) 
coming  on  when  bowels  have  not  moved  for  several  days, 
sensations  of  gurgluig  in  abdomen,  bloating  and  shght 
nau-sea.  Several  months  ago,  noted  painless  tumor  just 
to  the  left  of  the  navel.  This  has  increased  in  size  graduaUj^ 
since  when  first  noted. 

Obstipation. — VerA'  marked;  can  now  get  bowels  to  move 
only  with  great  difficulty:  never  noted  blood  or  pus  in 
stools. 

Appetite. — Fair. 

Weight. — ^Lost  15  pounds  in  past  3  months. 

Examinaiion. — Stocky,  weU-notirished,  thick-set  male; 
skin  pale,  saUow. 

Throat. — Peritonsihar  redness. 

Thorax. — Negative. 

Ahdornen. — Hat,  panniculus  moderately  thick.  Stom- 
ach shghtly  splashy  and  reaches  to  navel  in  mid-hne.  Deep 
tenderness  in  right  upper  abdominal  quach-ant  (pylorus?). 
In  the  left  h^TDOchonchium,  extending  from  the  rib  margin 


414  CANCER  OF  THE  STOMACH 

to  the  level  of  the  iliac  crest  is  a  nodular,  firm,  sUghtly 
movable,  not  tender  7nass.  It  is  about  3  inches  long  and 
1  to  2  inches  wide.  On  inflation  of  the  colon  the  tumor 
goes  apparently  posteriorly. 

Proctoscopic  Examination. — Negative.     Gastric  inflation 
seems  to  indicate  that  the  tumor  is  extragastric. 
Laboratory  Examinations: 

Blood.— Kg.,  90  per  cent.;  r.b.c,  5,000,000;  w.b.c, 
8,400. 

Stool. — Small,  hard,  firm,  no  blood. 

Test-meal. — Slight  gastric  stagnation.  Total  acidity, 
62;  freeHcl,  40. 

X-ray. — Stomach  moderately  dilated.  Outline  negative; 
peristalsis  active. 

Colon. — On  fluoroscopy  a  dense  mass  is  seen  in  the  lower 
half  of  the  descending  colon;  it  has  fairly  regular  outline 
and  appears  fixed  to  deep  structures.  The  mass  is  lost  on 
fiUing  the  colon  with  bismuth. 

Laparotomy. — Calcified  bezoar  stone,  densely  adherent 
to  the  posterior  wall  of  the  descending  colon;  chronic 
perforation. 

Chronic  obstipation  occurs  in  patients  past  middle  life. 
When  associated  with  weight  loss,  anemia,  and  irregular 
gastric  disturbance,  it  is  sometimes  confused  with  gastric 
malignancy.  In  these  instances  routine  anamnesis,  physical 
examination,  analysis  of  the  gastric  contents,  fluoroscopic 
examination  of  the  stomach  and  Roentgen  plates  made 
of  the  abdomen,  after  the  colon  has  been  injected  with 
barium  sulphate,  are  usually  sufficient  to  exclude  gastric 
cancer  and  show  malformation  or  malposition  of  portions 
of  the  large  bowel. 

Protozoic  Infections  of  the  Bowel. — Even  in  the  tem- 
perate zone  there  is  a  definite  class  of  toxic,  anemic,  dyspeptic 
individuals  who  present  themselves  for  diagnosis  and  in 
whom  cancer  may  be  suspected.  Intermittent  diarrhoea  is  a 
not  infrequent  finding.  Altered  blood  may  be  present  in 
the  stools.     The  patients  have  not  rarely  lost  consider- 


DIFFERENTIAL   DIAGNOSIS  415 

able  weight.  The  anamnesis  in  such  instances  discloses 
frequently  the  long-continued  drinking  of  contaminated 
water  or  the  eating  of  farm  produce  contaminated  by  water 
or  the  discharges  of  farm  cattle,  ducks,  etc.  The  disease 
seems  to  be  periodic  in  a  large  number  of  instances.  At- 
tacks of  diarrhoea  last  for  several  weeks,  alternating  with 
weeks,  or  even  months,  of  fair  health.  As  an  end  result 
anemia  develops.  It  is  usually  of  the  secondary  type, 
but  in  many  cases  there  is  an  excess  of  eosinophils.  The 
gastric  secretions  often  exhibit  absent  or  low  free  hy- 
drochloric acid.  Pancreatic  functional  tests  show  diminu- 
tion in  ferments.  The  examination  of  a  fresh  stool  on 
a  warm  microscopic  stage  reveals  protozoa  associated  with 
great  numbers  of  motile  and  non-motile  bacilli,  chains  of 
streptococci,  yeasts  and  undigested  food.  From  such 
cases  we  have  been  able  to  isolate  endamoeba,  trichomonas, 
cercomonas,  balantidium  coli  and  megastoma  entericum. 

In  the  average  case,  ridding  the  bowel  of  these  parasites 
goes  a  long  way  toward  getting  the  patient  well. 

X-ray  examination  of  the  stomach  and  bowel  in  these 
patients  is  negative. 

It  should  be  emphasized  that  the  above  type  of  case 
is  more  frequently  seen  than  is  recognized  in  current  text- 
books. These  protozoic  infections  are  chronic  and  usually 
intermittent.  Thej^  seem  to  be  due  to  precisely  the  same 
type  of  organisms  which,  under  proper  circumstances 
(chmate,  diet,  change  of  water,  etc.),  may  be  capable  of 
causing  acute  colitis,  with  or  without  hemorrhage,  ulcer- 
ation, abscess  formation,  and  the  like. 

Certain  constitutional  faults  are  occasionally  mistaken 
for  gastric  cancer,  and  in  fact  may  be  associated  with  it. 
Among  such  we  would  mention,  gout,  diabetes  and  nephri- 
tis.    The  clinical  history  of  these  cases  is  different  from 


416  CANCER  OF  THE  STOMACH 

that  of  cancer.  Analyses  of  the  test-meal,  feces,  blood  and 
urine  generally  bring  out  the  essential  differential  points. 
Examination  of  the  stomach  and  bowel  by  Roentgen  ray 
aids  in  estabhshing  the  diagnosis  of  non-mahgnant  disease. 

Certain  drug  addictions  produce  a  systemic  change  re- 
sembhng  that  of  gastric  cancer.  Among  such  are  the 
habitual  use  of  morphine,  heroin,  codein,  bromides  or 
the  smoking  of  opiates.  In  these  cases,  however,  careful 
examination  usually  demonstrates  needle-punctures,  alter- 
ations in  the  pupil,  in  the  mental  state,  in  the  urine.  To 
such  the  gastro-intestinal  findings  are  entirely  subordinate. 

In  this  class  of  patients  especially,  observations  must  be 
made  with  the  clothing  removed,  and  in  doubtful  cases  the 
patient  should  be  isolated  and  watched  until  the  definite 
cause  of  the  anomaly  is  established. 

Certain  tumors  of  the  abdominal  wall  may  be  considered, 
upon  casual  examination,  as  having  connection  with  the 
stomach.  Such  tumors  are  lipomata,  enchondromata,  cysts, 
abscesses,  or  fibro-sarcomata.  Careful  anamnesis,  physi- 
cal, chemical  and  x-ray  examinations  generally  differentiate 
such  conditions  quite  readily.  When  doubt  exists,  sections 
of  the  growth  may  be  removed,  or  the  tumor  may  be  as- 
pirated or  incised  in  order  to  permit  microscopic  study  of 
tissue  or  pus. 

REFERENCE 
Dock,  George:  Amer.  Jour.  Med.  Sciences,  1902. 


CHAPTER  XI 
SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH 

BY 

Albert  J.  Ochsxee,  B.S.,  M.D.,  LL.D.,  F.R.C.S.,  F.A.C.S. 

The  value  of  surgical  treatment  of  cancer  of  the  stomach 
primarily  depends:  first,  upon  an  early  diagnosis;  second, 
upon  the  complete  excision  of  all  of  the  cancerous  tissue; 
third,  upon  the  fact  that  the  traumatism  caused  by  the 
operation  is  within  the  margin  of  safety  of  the  individual 
patient;  fourth,  upon  a  satisfactory  mechanical  result 
which  wiU  enable  the  patient  to  live  comfortably  with  his 
changed  digestive  apparatus,  and  fifth,  upon  careful  after- 
treatment. 

Fortunately,  patients  suffering  from  cancer  of  the 
stomach  come  for  surgical  treatment  earlier  in  the  course 
of  the  disease  than  in  former  times,  and  as  a  result  of  this 
condition  it  is  possible  to  make  a  complete  excision  in  a 
larger  number  of  cases.  There  is  a  class  in  which  it  may 
not  be  possible  to  make  a  differential  diagnosis  positively 
between  cancer  of  the  stomach,  ulcer  of  the  stomach  or 
duodenum,  disease  of  the  gall-bladder,  adhesions  in  the 
region  of  the  pylorus,  or  obstruction  to  the  pylorus  due  to 
cicatricial  contraction  resulting  from  a  previous  ulcer.  It 
is  in  this  class  of  case  that  the  surgeon  has  more  frequently 
committed  errors  than  in  any  other  group.  It  is  without 
doubt,  in  this  type  of  case,  that  an  operation  should 
always  be  performed,  because  whatever  condition  may  be 
found  after  the  abdomen  has  been  opened,  it  is  proper  that 
the  condition  be  treated  surgically. 

27  417 


418  GANGER  OF  THE  STOMAGH 

The  pride  or  personal  conceit  of  the  surgeon  may  suffer 
because  of  his  inabihty  to  make  a  positive  diagnosis  in  these 
cases  and  he  may  wish  to  continue  his  observations  for  a 
number  of  weeks  or  months  in  order  to  be  certain  before 
operating,  so  that  he  may  be  able  to  demonstrate  the 
correctness  of  his  diagnosis  at  the  time  of  the  operation. 
This  plan  is,  however,  exceedingly  bad  because  in  case  of 
cancer,  the  condition  may  have  progressed  to  such  an 
extent  that  while  a  permanent  cure  might  have  been 
accomplished  with  an  early  operation,  the  late  operation 
will  result  at  best  only  in  a  temporary  improvement.  Con- 
sequently, after  a  very  thorough  examination  has  been  made, 
if  there  is  still  doubt,  an  operation  should  invariably  be 
performed. 

COMPLETE  EXCISION 

By  far  the  greatest  number  of  cases  in  which  the  complete 
excision  of  all  malignant  tissue  is  feasible,  belong  to  a 
class  in  which  it  was  not  possible  to  make  a  positive 
differential  diagnosis  between  cancer  and  ulcer.  There 
is,  however,  a  class  of  cases  in  which  the  cancer  seems  to 
be  almost  entirely  confined  to  the  mucous  membrane,  and 
does  not  penetrate  the  entire  wall  of  the  stomach  and  is 
of  sufficient  firmness  to  prevent  the  loosening  of  cells  to 
be  carried  to  distant  points  for  a  considerable  period  of 
time.  In  this  group  of  cases  it  is  also  possible  to  remove  all 
of  the  cancerous  tissue. 

In  planning  the  operation,  one  should  constantly  bear 
in  mind  the  distribution  of  lymph  channels  and  lymph 
nodes  described  by  Cuneo,  because  in  this  way  it  will  be 
possible  to  remove  the  tissue  which  is  likely  to  be  in- 
fected with  cancer  beyond  the  tumor  itself,  together  with 
the  lymph  nodes  which  are  most  likely  to  contain  cancerous 
infection. 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH       419 

Preparation  for  Operation. — The  preparation  for  all 
operations  for  the  relief  of  cancer  of  the  stomach  is  the 
same,  consequently  it  may  be  given  here  and  then  it  may 
be  applied  to  all  of  the  operations  upon  the  stomach  which 
will  be  described  through  this  Chapter. 

First,  an  attempt  must  be  made  to  prevent  as  much  as 
possible  the  introduction  into  the  stomach  of  septic 
material.  For  this  reason  it  is  important  to  free  the  mouth 
and  the  nasal  passages  as  thoroughly  as  possible  of  all 
infective  material  before  the  operation  is  undertaken. 
If  the  patient  has  decayed  teeth  or  roots,  or  both,  or  suffers 
from  pyorrhea,  or  from  catarrh,  or  from  tonsillar  infec- 
tion, all  of  these  conditions  should  be  disposed  of  by 
proper  ■  treatment,  provided  this  treatment  will  not  con- 
sume a  sufficient  amount  of  time  to  endanger  the  patient's 
condition  from  progression  of  his  disease.  In  case  of  such 
danger,  it  is  better  to  thoroughly  spray  the  nasal  cavities 
and  the  pharynx  repeatedly  with  some  mild  antiseptic 
solution  for  24  hours  preceding  the  operation,  giving  the 
patient  a  good  antiseptic  gargle  to  thoroughly  cleanse  the 
teeth  a  number  of  times  during  the  24  hours  preceding  the 
operation,  and  to  paint  the  roots  of  the  teeth  in  case  of 
pyorrhea  with  tincture  of  iodine;  also  to  cleanse  the  tongue 
thoroughly  and  to  get  the  cavities  of  the  nose  and  mouth 
in  as  nearly  an  aseptic  condition  as  we  are  able  to  get  them. 

No  noiurishment  should  be  given  that  contains  any 
septic  material.  It  is  best  to  give  these  patients  broth 
only  for  24  hours  preceding  the  operation.  The  stomach 
should  be  thoroughly  irrigated  until  the  return  fluid  is 
perfectly  clear.  The  patient  should  be  given  2  ounces 
of  castor  oil  the  day  before  the  operation,  because  this 
will  carry  away  a  great  amount  of  foul  material.  It  is 
well  to  place  this  castor  oil  in  the  stomach  through  the 


420  CANCER  OF  THE  STOMACH 

stomach  tube,  after  thorough  irrigation  of  the  viscus  the 
day  before  the  operation  after  all  of  the  irrigating  fluid 
has  been  siphoned  out.  By  doing  this,  even  though  the 
passage  between  the  stomach  and  the  duodenum  may  be 
almost  completely  occluded  because  of  the  presence  of 
the  tumor,  a  sufficient  amount  of  the  oil  will  pass  through 
this  space,  as  a  rule,  to  completely  cleanse  the  intestines. 
The  stomach  should  be  washed  out  again  within  an  hour 
preceding  the  operation.  It  is  well  to  thoroughly  cocain- 
ize the  pharynx  with  a  spray  of  2  per  cent,  cocaine  and  to 
permit  the  patient  to  swallow  this  in  order  that  the  pharynx 
and  the  esophagus  will  become  properly  anesthetized  by 
this  substance.  It  is  best  to  wait  about  12  minutes  after 
the  spraying  has  ceased  in  order  that  the  cocaine  may 
have  completely  removed  all  sensation  from  the  parts 
over  which  the  stomach  tube  is  to  be  passed.  Not  more 
than  2  drams  of  a  2  per  cent,  solution  of  cocaine  should  be 
used  for  this  purpose,  this  amount  being  quite  sufficient 
and  there  being  no  danger  from  cocaine  poisoning  if  no 
larger  amount  is  used. 

The  patient  should,  of  course,  have  all  of  the  other 
ordinary  preparations,  such  as  a  warm  bath  previous  to  the 
operation,  etc.  The  abdominal  wall  should  be  treated  in 
the  manner  which  is  usually  employed  in  preparing  for  all 
abdominal  sections. 

Cancers  not  Located  in  or  Near  the  Pylorus. — The  rare 
cases  of  cancer  located  away  from  the  pylorus  which  come 
under  surgical  treatment  sufficiently  early  to  permit  com- 
plete excision,  are  usually  encountered  accidentally  either 
in  the  form  of  sarcoma  of  which  we  have  had  a  few  cases, 
or  in  the  form  of  cancer  developing  at  the  bottom  or  in  the 
edge  of  a  gastric  ulcer.  In  the  case  of  sarcoma,  metastatic 
tumors  are  not  common  early  in  the  development  of  these 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      421 

growths  and  consequently  it  is  possible  to  make  a  complete 
excision  by  remo^"ing  tissue  3  cm.  in  every  direction 
from  the  primary  growth  and  then  closing  the  wound  left 
in  the  stomach  in  a  manner  to  prevent  obstruction  from 
cicatricial  contraction. 

Usually  the  Une  of  suture  should  be  in  a  transverse  or  an 
obhque  direction,  but  the  location  and  the  extent  of  the 
growth  in  the  indi^ddual  case  must  determine  the  direction 
of  the  closure.  In  case  the  growth  involves  the  lower  end 
of  the  esophagus,  the  chances  of  recovery  after  removal  are 
so  shght  that  the  operation  need  scarcely  be  considered 
at  the  present  time. 

Willy  ^Nleyer  is  developing  a  technique  in  the  use  of  his 
differential  air-pressure  cabinet,  with  which  he  hopes  in  time 
to  succeed  in  satisfactorily  remo^dng  such  growths  and  by 
reuniting  the  esophagus  and  stomach,  by  a  tube  constructed 
from  a  portion  of  the  stomach  with  the  remnant  of  the 
esophagus,  prolong  life.  At  the  present  time  it  is  too  early 
to  discuss  this  operation. 

Carl  Beck  has  devised  an  operation  in  which  he  utihzes  the 
lower  portion  of  the  stomach  for  the  purpose  of  construct- 
ing a  tube,  which  can  be  used  as  an  artificial  esophagus, 
to  be  carried  upward  underneath  the  skin  of  the  chest,  in 
cases  of  carcinoma  of  the  esophagus  or  of  the  cardiac  end 
of  the  stomach  invohT.ng  the  lower  end  of  the  esophagus. 
Unfortunateh^  these  cases  usuall}^  die  so  soon  after  the 
operation  from  the  recurrence  of  the  mahgnant  growth  that 
it  is  doubtful  whether  so  severe  and  so  extensive  an  opera- 
tion is  indicated  in  a  patient  whose  hfe  expectancy  is 
relatively  short.  In  case  one  does  not  feel  warranted 
in  performing  so  extensive  an  operation  in  this  class  of 
cases  which  have  advanced  so  far  that  food  can  no  longer 


422  CANCER  OF  THE  STOMACH 

be  taken  through  the  esophagus,  it  is  well  to  perform  a 
gastrostomy. 

Technique  of  Operation. — {WitzeVs  Gastrostomy). — An 
incision  5  cm.  long  is  made  through  the  edge  of  the  left 
rectus  abdominis  muscle  just  below  the  costal  margin  and  3 
cm.  to  the  left  of  the  median  line.  The  incision  is  carried 
through  all  layers  into  the  peritoneal  cavity.  The  stomach 
is  then  examined  to  determine  the  exact  extent  and  loca- 
tion of  the  tumor.  A  fold  of  the  stomach-wall  is  drawn 
through  the  abdominal  opening,  the  fold  being  chosen  far 
enough  away  from  the  growth  to  prevent  its  involvement  in 
the  advance  of  the  mahgnant  growth.  The  skin  outside  of 
the  deep  fascia  is  then  undermined  upward  over  the  costal 
margin  for  a  distance  of  4  cm.  and  a  transverse  incision  is 
made  through  the  skin.  The  undermined  space  is  loosened 
to  a  width  of  3  cm.  in  order  that  the  fold  of  the  stomach, 
which  is  to  be  drawn  through  this  space,  may  not  be  unduly 
compressed  and  thus  produce  gangrene  of  the  stomach 
wall.  The  tip  of  this  fold,  13^  cm.  long,  is  permitted  to 
project  through  the  transverse  opening  and  is  sutured  in 
plac  e  with  six  or  eight  fine,  silk  sutures .  A  sec  ond  row  of  fine, 
silk  sutures  is  placed  so  as  to  unite  the  wall  of  the  stomach 
with  the  peritoneum  and  transversahs  fascia  and  a  few 
additional  sutures  are  placed  between  the  stomach  wall 
and  the  edges  of  the  rectus  abdominis  muscle  and  the 
anterior  sheath  of  the  rectus  abdominis  muscle.  The 
wound  is  then  closed.  * 

If  the  patient  is  suffering  from  starvation,  the  fold  of 
stomach  projecting  beyond  the  transverse  incision  is  at 
once  opened  and  a  Jacobson  retention  catheter  is  passed 
into  the  stomach  and  some  concentrated  food  and  water 
are  at  once  administered  through  this  catheter  whose 
distal  end  is  closed  by  means  of  a  cork  or  a  clamp  during 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      423 

the  intervals  between  feedings.  In  these  cases  the  patient 
should  receive  nourishment  every  2  hours.  If  the  patient's 
condition  is  not  so  serious  it  is  well  to  postpone  opening  the 
stomach  for  24  or  48  hours,  until  a  strong  adhesion  between 
the  stomach  and  surrounding  tissue  has  been  formed,  in 
order  that  there  may  not  be  any  infection  from  the  stomach 
wound.  The  danger  from  such  an  infection  is  so  slight  that 
it  need  not  interfere  with  the  completion  of  the  operation 
if  the  patient  is  in  need  of  nourishment.  This  arrangement 
will  prevent  leakage  from  the  stomach  perfectly  and 
permanently. 

There  are  many  other  operations  equally  as  satisfactory 
as  the  one  described  (which  was  introduced  by  Professor 
Witzel)  but  none  of  them  are  simpler  or  more  satisfactory 
than  the  above. 

In  case  the  entire  cardiac  end  of  the  stomach  has  been 
involved  in  a  mahgnant  growth,  then  it  may  become  neces- 
sary to  make  the  gastrostomy  to  the  right  of  the  median 
hne,  and  in  that  case  the  amount  of  stomach  wall  is  usually 
not  sufficient  for  this  operation  and  the  operation  intro- 
duced by  Senn  will  give  fairly  satisfactory  results. 

Senn's  Operation. — This  operation  consists  in  making  a 
small  puncture  in  the  available  stomach  wall  and  intro- 
ducing through  this  a  Jacobson's  retention  catheter,  which 
has  been  stretched  upon  a  probe  so  that  the  diameter  of  the 
rubber  tubing  is  greatly  reduced  in  order  that  it  may  thor- 
oughly occlude  the  puncture  opening  in  the  stomach  wall 
upon  contraction.  A  purse-string  suture  is  then  passed 
through  the  stomach  wall  3^  cm.  from  the  rubber  tubing  and 
tied  snugly  about  the  tubing.  It  is  best  to  use  fine  silk  for 
this  purpose.  This  is  introduced  with  a  fine,  curved  needle 
in  order  that  all  of  the  layers  of  the  stomach  wall  down  to, 
but  not  through,  the  mucous  membrane,  may  be  engaged  in 


424  CANCER   OF   THE    STOMACH 

the  suture  in  order  that  it  may  have  a  substantial  hold, 
because  of  its  passing  through  the  submucous  connective 
tissue.  A  second,  third  and  a  fourth  purse-string  suture  of 
the  same  kind  are  introduced  successively  and  then  the 
stomach  is  attached  by  means  of  fine  silk  sutures  to  the 
peritoneum  and  transversalis  fascia  and  the  tube  is  per- 
mitted to  pass  out  through  the  abdominal  wound.  This  is 
closed  by  means  of  sutures  on  each  side  of  this  tube.  In 
case  there  is  leakage  around  the  tubing,  which  may  occur  if 
the  patient  lives  for  a  number  of  months  after  the  operation, 
it  is  well  to  increase  the  size  of  the  rubber  tube  sufficiently 
to  produce  a  perfect  closure  of  this  canal. 

In  order  that  the  patient  may  have  the  pleasure  of  eating, 
he  may  chew  the  food  he  takes  very  thoroughly,  place  it 
in  the  barrel  of  a  large  glass  syringe  and  then  inject  it  into 
his  stomach  through  this  tube.  Aside  from  the  satisfac- 
tion the  patient  has  in  chewing  the  food,  there  is  the  ad- 
vantage of  having  the  food  mixed  with  saliva.  Until  the 
patient  becomes  accustomed  to  being  fed  in  this  manner  it 
is  well  to  continue  the  administration  of  concentrated 
food  by  means  of  enemata  given  every  3  hours,  and  also 
by  the  administration  of  normal  salt  solution  by  the  drop 
method  of  proctoclysis.  In  most  of  these  cases,  the 
administration  of  from  5  to  10  drops  of  eucalyptus  oil,  in  a 
little  cream,  by  mouth  from  3  to  6  times  a  day,  serves  to 
disinfect  the  malignant  growth  in  the  lower  end  of  the 
esophagus  and  to  increase  the  comfort  of  the  patient. 

EXCISION  OF  CIRCUMSCRIBED  GROWTHS  NOT  LOCATED  IN  THE 
REGION  OF  THE  PYLORUS  OR  THE  ESOPHAGUS 

In  order  to  reduce  the  traumatism  to  a  minimum,  it  is  well 
to  make  a  very  large  abdominal  incision,  so  that  the 
stomach  may  be  brought  out  into  view  without  unneces- 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      425 

sary  tension  or  injury.  A  long  stomach  clamp  with  blades 
sufficiently  thin  and  covered  with  rubber  tubes  to  prevent 
injury  from  pressure,  is  applied  at  a  distance  of  10  cm. 
above  and  below  the  growth,  in  order  to  compress  the  blood- 
vessels supplying  the  region  of  the  stomach  to  be  operated. 
A  thin,  silk  suture  is  then  applied  around  each  individual 
vessel  4  cm.  away  from  the  growth  in  every  direction. 
(Before  beginning  the  operation  the  stomach  is  thoroughly 
irrigated  until  the  returning  water  is  perfectly  clear.  It  is 
well  to  use  normal  salt  solution  at  a  temperature  of  105°  F. 
for  this  purpose.)  The  stomach  is  then  opened  dkectly  to 
the  outer  side  of  the  line  of  sutures  controlling  the  blood- 
vessels and  fine  tenaculum  forceps  are  applied  in  such  a 
manner  that  later  they  may  be  utilized  as  land-marks  in 
closing  the  defect  in  the  stomach.  In  case  there  is  bleeding 
from  the  mucous  membrane,  the  bleeding  point  is  caught 
and  ligated.  After  the  entire  growth,  together  with  3  cm. 
of  the  surrounding  tissue,  has  been  removed,  the  tenaculum 
forceps  are  utilized  for  bringing  the  edges  together.  A  row 
of  sutures  of  thin,  chromicized  catgut  threaded  double  is 
used  for  uniting  the  mucous  membrane.  A  second  row  of 
fine  silk  sutures  is  used  for  uniting  the  muscular  layer  and 
over  this  a  row  of  fine,  silk  sutures  is  applied  grasping  all  of 
the  layers  down  to  but  not  through  the  mucous  membrane. 
In  this  way  a  perfect  union  can  be  accomplished  without 
much  infolding  of  the  stomach  wall.  In  case  the  tumor  is 
small,  the  Connell  suture  may  be  used  instead  of  this 
method.  The  suture  is  passed  through  all  of  the  layers  of 
the  edge  of  the  wound  on  either  side,  so  that  the  serous 
surface  is  placed  in  apposition  throughout.  A  second  row 
of  sutures  corresponding  to  the  third  row  which  has  just 
been  described  is  placed  over  this  and  in  this  way  the  Connell 
suture  is  reinforced.     In  either  of  these  cases  there  can  be 


426  CANCER  OF  THE  STOMACH 

no  hemorrhage  because  all  of  the  blood-vessels  are  thor- 
oughly controlled  by  the  various  rows  of   sutures. 

In  case  the  growth  is  so  near  the  pylorus  that  it  will  be 
necessary  to  constrict  the  pyloric  end  of  the  stomach  by 
the  apphcation  of  the  sutures  closing  the  defect,  it  is  best 
to  plan  a  gastro-enterostomy  in  addition  to  the  excision  of 
the  growth.  This  will,  however,  be  different  in  no  way 
from  the  operation  to  be  described  in  connection  with  the 
treatment  of  carcinoma  of  the  pylorus.  It  is  consequently 
not  necessary  to  explain  it  at  this  point. 

CARCINOMA  OF  THE  PYLORUS 

Nearly  all  of  the  cases  of  cancer  of  the  stomach  which 
come  early  enough  to  make  it  reasonable  to  expect  a 
permanent  cure  following  an  operation,  are  located  in 
the  region  of  the  pylorus.  This  is  also  true  of  a  fairly  large 
class  of  cases  which  can  be  much  benefited  by  an  opera- 
tion although  there  is  no  possibihty  of  a  permanent  cure. 
In  nearly  all  of  these  cases  the  obstruction  to  the  pylorus 
is  so  marked  that  practically  no  food  can  pass  into  the 
small  intestines.  This  condition  causes  starvation,  and 
also  makes  a  foul  retention  cavity  of  the  remaining  por- 
tion of  the  stomach,  in  which  the  remnants  of  food  and  the 
mucus  secreted  by  the  stomach  and  the  broken-down 
ulcerating  carcinomatous  tissue,  produce  a  decomposing 
substance,  portions  of  which  will  be  absorbed  through 
the  stomach  walls  and  will  cause  more  or  less  severe 
symptoms  of  cachexia. 

On  the  one  hand  these  patients  are  starved  and  on  the 
other  hand  they  are  poisoned  by  these  foul  accumulations. 
Moreover,  the  vomiting  which  is  caused  byjthe  latter 
serves  to  irritate  the  cancerous  growth  so  that  these 
patients  are  in  a  most  deplorable  condition.     Even  with 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      427 

repeated  lavage,  it  is  not  possible  to  keep  the  stomach 
even  fairly  clean.  These  patients  gain  enormously  by  a 
properly  planned  and  executed  gastro-enterostomy,  be- 
cause this  will  permit  nourishment  from  the  stomach  to 
reach  the  intestines  and  will  remove  the  suffering  from 
starvation.  It  will  prevent  the  accumulation  of  de- 
composing material  in  the  stomach  and  will  thus  remove 
the  auto-intoxication.  It  will  in  the  same  way  alleviate 
the  nausea  and  vomiting  and  the  irritation  from  the 
latter  to  the  tumor.  The  ulcerated  surface  of  the  tumor 
is  likely  to  become  clean  as  a  result  of  this  improved 
condition. 

The  patient's  life  is  naturally  prolonged  and  his  comfort 
is  enormously  increased  by  these  changed  conditions. 
Moreover,  a  patient  may  gain  so  much  in  strength  that  al- 
though the  removal  of  the  growth  at  the  primary  opera- 
tion would  undoubtedly  have  resulted  in  death  from 
shock,  the  increase  in  strength  as  a  result  of  the  improved 
nutrition  and  the  absence  of  the  other  distressing  con- 
ditions may  make  a  secondary  operation  fairly,  if  not 
perfectly,  safe. 

This  leads  us  to  the  plan  of  operating  for  the  relief  of 
cancer  of  the  pylorus  in  two  stages  in  these  greatly  reduced 
patients.  In  order  to  perform  the  operation  satisfactorily 
in  two  stages,  however,  it  is  of  the  greatest  importance  that 
the  first  operation  be  so  performed  that  the  intraabdominal 
condition  will  be  favorable  for  performing  the  second 
operation  at  a  later  date.  This  presupposes  that  the 
first  operation  will  not  result  in  extensive  adhesions,  but 
simply  in  a  union  between  the  jejunum  and  the  stomach 
at  a  point  suflSciently  distant  from  the  malignant  growth 
to  make  its  complete  excision  possible  at  the  second 
operation.     If  the  first  operation  is  followed  by  extensive 


428  CANCER    OF   THE    STOMACH 

adhesions,  then  the  second  operation  is  liable  to  fail  from 
two  causes.  In  the  first  place  the  extensive  loosening 
from  adhesions  is  likely  to  produce  a  degree  of  shock  so 
severe  that  the  patient  will  succumb  to  the  operation  a 
short  time  after  it  has  been  performed.  In  the  second 
place  the  traumatism  causing  these  adhesions  is  likely  to 
result  in  transplantation  of  the  cancerous  tissue,  so  that 
the  adhesions  will  be  filled  with  secondary  carcinomatous 
growths. 

The  location  of  the  gastro-enterostomy  opening  in  the 
stomach  must  be  chosen  so  that  practically  the  lowest 
portion  of  the  stomach  will  contain  this  opening,  pro- 
vided it  is  possible  by  doing  this  to  remain  far  enough 
away  from  the  original  growth  to  make  its  excision  possible 
or  to  prevent  its  encroaching  upon  this  opening  in  cases 
which  are  so  far  advanced  that  complete  removal  is  not 
possible  at  a  later  period. 

The  operation  of  gastro-enterostomy  is  the  same  without 
regard  to  the  other  operation,  consequently  one  descrip- 
tion will  suffice  as  well  for  cases  that  are  simply  to  have 
this  operation  for  temporary  relief,  for  those  who  are 
later  to  have  the  excision  of  the  growth,  and  for  those  in 
whom  the  gastro-enterostony  and  the  excision  are  to  be 
performed  at  the  same  time. 

Posterior  Gastro-enterostomy. — During  the  early  period 
of  stomach  surgery  we  performed  over  200  anterior  gas- 
tro-enterostomies,  always  choosing  the  lowest  point  in  the 
stomach  in  accordance  with  a  suggestion  made  by  W.  J. 
Mayo  15  years  ago.  During  the  past  years  we  have,  how- 
ever, chosen  the  posterior  gastro-enterostomy  with  a 
short  loop  of  the  jejunum  in  all  cases  in  which  this  was  not 
prevented  by  the  location  of  the  tumor,  not  that  the  results 
are  any  better,  but  because  it  has  seemed  to  be  the  opera- 


SURGICAL  TREATMENT  OF  CANCER  OE  THE  STOMACH      429 

tion  which  impressed  one  as  being  more  nearly  correct  from 
a  mechanical  standpoint.  In  cases  in  which  it  is  likely 
that  a  secondary  operation  must  be  performed,  the  incision 
should  be  made  through  the  median  line  from  the  ensif orm 
cartilage  of  the  sternum  to  a  point  3  cm.  below  the  umbilicus. 
This  will   provide   an   abundance    of   space  for  bringing 


Fig.  85. — Anterior  gastrojejunostomy  made  with  gastric  clamp  for  in- 
operable carcinoma  of  pyloric  third  of  stomach  with  obstruction.  A  long 
loose  loop  of  jejunum  is  carried  over  the  greater  omentum  and  colon.  This 
is  held  in  one  half  of  the  rubber  covered  gastric  clamp,  the  other  half  of 
which  is  open  to  receive  the  portion  of  stomach  held  by  the  mouse-tooth 
clamps.  The  anastomosis  is  made  just  anterior  to  the  greater  curvature 
of  the  stomach  and  as  close  to  the  tumor  as  possible.  Arrow  indicates  the 
direction  of  flow  in  the  bowel. 

the  stomach  and  intestine  into  view  with  the  slightest 
amount  of  traumatism. 

The  skin  to  each  side  of  the  abdominal  incision  is  covered 
with  towels  and  then  the  omentum  and  transverse  colon 
are  carried  upward  in  order  to  expose  the  jejunum  where  it 
emerges  from  beneath  the  transverse  mesocolon.     It  is 


430 


CONGER    OF   THE    STOMACH 


well  to  have  the  mesocolon  spread  out  so  that  one  can  fairly 
see  its  blood-vessels,  in  order  that  these  will  not  be  injured 
during  the  next  step  of  the  operation,  which  consists 
of  the  tearing  of  a  hole  in  this  structure  sufficiently  large 
to  permit  the  union  between  the  lower  posterior  wall  of 
the  stomach  and  the  loop  of  the  jejunum.  The  stomach 
wall  is  drawn  through  this  opening  and  a  point  as  far  away 


Fig.  86. — Diagram  to  show  the  relations  in  a  completed  anterior 
gastro-enterostomy. 

as  possible  from  the  malignant  growth  is  chosen.  A  pair 
of  fine-toothed  clamps  is  apphed  to  the  lower  margin  of 
this  space  in  close  proximity  to  the  gastro-epiploic  vessels. 
A  second  pan-  of  forceps  is  appUed  upward  and  a  little  to 
the  right  at  a  distance  of  5  cm.  from  the  first  pair.  A 
straight  line  between  these  two  forceps  indicates  the  location 
of  the  gastro-enterostomy  opening  to  be  made  presently. 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      431 


This  fold  of  stomach  wall  is  now  drawn  through  a  pair  of 
gastro-enterostomy  forceps  and  the  transverse  colon  and 
omentum  are  replaced  in  the  abdominal  cavity  and  held  in 


-N^ 


^;-'o^-^'^* 


Fig.  87. — ^Steps  in  the  making  of  posterior  gastrojejunostomy  by  means 
of  the  gastric  clamp.  Portion  of  greater  curvature  nearest  the  pylorus 
brought  through  a  tear  in  transverse  mesocolon.  Loop  of  jejunum  in  posi- 
tion for  application  of  clamp. 

position  by  means  of  gauze  pads  saturated  with  warm 
normal  salt  solution.  The  loop  of  jejunum  nearest  the 
transverse  mesocolon  is  then  brought  up  into  view  and  a 


432 


CANCER   OF   THE    STOMACH 


4- 


Fig.  88. — Posterior  gastrojejunostomj'  for  inoperable  carcinoma  of 
lesser  curvature  with  obstruction  of  pylorus.  Gastric  clamp  not  used.  The 
colon  and  omentum  have  been  reflected  upwards,  an  opening  made  into  the 
transverse  meso-colon,  the  greater  curvature  of  the  stomach  brought  through 
the  opening  and  held  with  mouse-tooth  clamps.  The  loop  of  jejunum,  5  cm. 
from  its  beginning,  is  attached  with  a  continuous  row  of  silk  sutures  to  the 
stomach.  Initial  openings  through  both  stomach  and  jejunum,  8  cm.  long 
and  extending  to  but  not  through  the  mucosae,  have  been  made. 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH       433 

pair  of  fine-toothed  clamps  is  placed  upon  the  wall  of  the 
intestine  farthest  away  from  its  mesentery,  5  cm.  from 
the  mesentery  of  the  transverse  colon.  A  second  pair  of 
fine-toothed  clamps  is  appUed  in  the  same  manner  6  cm. 
distally  from  this  first  pair,  the  distance  being  slightly 
greater  than  that  between  the  two  forceps  on  the  stomach 
wall,  because  the  longitudinal  fibers  of  the  jejunum  will 
contract  and  bring  these  forceps  near  together.  The  fold 
of  the  jejunum  is  then  drawn  through  the  second  blade  of 
the  gastro-enterostomy  forceps  in  such  a  manner  that  the 


Fig.  89. — The  gastric  clamp  applied,  the  posterior  row  of)  Lembert 
sutures  in  place  and  the  incisions  through  walls  of  stomach  and  jejunum 
made  as  close  to  Lembert  sutures  as  possible  and  extending  to  the  mucosae. 

forceps  nearest  the  transverse  mesocolon  will  be  opposite 
the  forceps  farthest  away  from  the  gastro-epiploic  vessels, 
and  the  other  two  forceps  will  also  be  in  apposition. 

It  is  well  now  to  make  a  straight  incision  through  the 
peritoneum  and  muscle  down  to  but  not  through  the  mucous 
membrane  of  the  stomach  wall  between  the  two  fine-toothed 
clamps  which  have  been  applied,  and  also  between  the  two 
fine-toothed  clamps  on  the  wall  of  the  jejunum.  The 
incision  will  mark  the  location  of  the  gastro-enterostomy 
opening.  A  fine,  silk  suture  threaded  in  an  ordinary  cambric 
needle  is  ased  to  unite  the  serous  surfaces.     The  thread 


434 


CANCER    OF    THE    STOMACH 


should  be  about  75  cm.  long  and  should  be  used  double  so 
as  to  prevent  slipping  and  twisting.  It  is  well  to  begin 
this  suture  at  a  point  opposite  the  distal  end  of  the  gas- 
tro-enterostomy  clamp  and  to  make  the  sutures  so  that  the 
serous  surface  will  be  in  perfect  coaptation,  leaving  a  fair 
margin  of  2  or  3  mm.  between  this  row  of  sutures  and  the 
edge  of  the  incision.  This  row  of  sutures  is  carried  3^  cm. 
beyond  the  end  of  the  incision.  The  needle  and  thread  are 
then  placed  to  one  side  for  future  use.     A  fine,  double 


Fig.  90. — Row    of    Connell   catgut   sutures   being   applied. 

chromicized  catgut  suture,  the  surface  of  which  has  been 
rendered  smooth  by  rubbing  with  vaseline  is  next  employed 
as  a  deep  suture.  This  suture  is  begun  at  a  point  opposite 
to  the  conclusion  of  the  serous  suture  in  order  that  the  knots 
of  this  suture  may  not  be  opposite  the  knots  of  the  silk 
suture  previously  described.  This  suture  is  carried  into 
the  lumen  of  the  small  intestine,  then  across  the  edge  of 
the  incision  taking  a  bite  of  about  1  mm.  of  the  small  in- 
testine and  the  stomach  so  that  it  includes  all  of  the  layers 
of  both  structures.  The  first  suture  is  tied  and  then  a 
continuous  suture  is  applied  with  the  stitches  near  enough 
to  each  other  to  absolutely  prevent  hemorrhage.  This 
suture  is  carried  to  the  distal  end  of  both  incisions  and  then 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      435 


Fig.  91. — A  continuous  row  of  fine  chromicized  catgut  sutures  extending 
through  and  through  the  mucosae  of  stomach  and  of  jejunum.  This  catgut 
suture  is  begun  at  the  opposite  end  from  which  the  silk  suture  was  started 
and  the  ends  of  both  of  these  sutures  are  left  long. 


Fig.  92. — Clamp  removed   and  outer  Lembert   sutures  in  place. 


436 


CANCER    OF    THE    STOMACH 


passed  out  through  the  wall  of  the  stomach  at  a  point 
opposite  the  distal  end  of  the  gastro-enterostomy  clamps. 
The  lumen  of  the  stomach  is  now  opened  by  means  of 
scissors,  care  being  taken  to  so  cut  the  mucous  membrane 
along  the  edge  of  the  incision  which  has  already  been  made, 
that  all  the  layers  of  the  stomach  wall  present  a  smooth 
surface. 


^3- 


X 


Fig.  93. — Showing  the  anterior  Lembert  silk  stitch,  which  entirely  sur- 
rounds the  inner  Connell  row  of  sutures,  and  which  is  a  continuation  of  the 
first  row  of  silk  sutures  applied. 

It  is  important  to  be  careful  to  sponge  away  any  mucus 
which  may  be  emptied  upon  the  wound  surface  when  the 
stomach  is  opened,  but  in  doing  this  one  should  be  careful  not 
to  loosen  the  mucous  membrane  from  the  overlying  muscle 
and  in  no  way  to  traumatize  the  delicate  tissues  composing 
the  edge  of  this  wound.  The  edge  is  then  caught  at  three 
points  with  delicate  fine-toothed  clamps  constructed  for  this 
purpose,  so  that  these  layers  may  be  held  in  their  proper 


SURGICAL  TREATMENT  OF  CANXEE  OF  THE   STOMACH       437 

position  during  the  remaining  steps  of  the  operation.  The 
same  steps  are  then  carried  out  in  opening  the  jejunum,  care 
being  taken  to  place  the  fine-toothed  clamps  opposite  those 
on  the  stomach  wound  edge.  In  case  the  mucous  mem- 
brane overlying  the  posterior  two  rows  of  sutures  does  not  fall 
into  absolutely  close  apposition,  it  is  best  to  place  a  fine 
silk,  continuous  suture  uniting  this  mucous  layer  which, 
however,  is  not  necessary  in  case  there  is  perfect  coaptation. 
The  anterior  opening  is  now  closed  by  applying  the  suture 
introduced  by  C.  H.  Mayo.  This  is  a  continuation  of  the 
continuous  catgut  suture  already  applied.  The  suture  is 
carried  through  all  the  lavers  of  the  intestine  from  without 


Fig.  94. — Extra,  stay,  silk-stitches  placed  at  each  end  of  the  anastomosis. 
Edges  of  opening  in  transverse  mesocolon  sutured  to  stomach  1  cm.  from 
anastomosis,  with  interrupted  silk  sutures. 

inward,  then  from  within  outward,  then  across  the  space 
and  then  through  the  stomach  wall  in  the  same  manner 
from  without  inward  grasping  all  layers,  then  from  within 
outward,  then  across  the  space  to  the  jejunum.  These 
steps  are  repeated  until  the  entire  anterior  wound  has  been 
closed  and  the  point  is  reached  at  which  the  catgut  suture 
was  begun.  The  end  of  the  suture  containing  the  needle 
is  then  tied  to  the  portion  of  the  catgut  at  the  beginning  of 
the  suture  which  was  left  long  for  this  ptu^pose.  This 
suture  inverts  every  portion  of  the  stomach  and  intestinal 


438 


CANCER    OF    THE    STOMACH 


wall  so  that  the  serous  surfaces  are  in  apposition.  The 
needle  containing  the  original  suture  is  then  taken  up  and  a 
row  of  Lembert  sutures  is  applied  covering  up  the  catgut 
suture  Hne,  which  is  continued  at  the  point  at  which  this 
suture  was  started  and  there  tied  to  the  ends  which  were 
left  long  for  this  purpose.  At  this  point  there  is  some 
danger  of  strain  and  in  order  to  overcome  this,  two  or  three 


Fig.  95. — Diagram  to  show  relations   in   a  posterior  gastro-jejunostomy. 
A,  Greater  curvature;  B,  pylorus;  C,  duodeno-jejunal  flexure. 

interrupted  silk  sutures  are  applied,  attaching  the  stomach 
wall  to  the  jejunum.  It  is  well  to  apply  the  same  number 
of  sutures  at  a  point  directly  opposite  this,  because  that 
point  is  also  likely  to  require  a  little  additional  protection. 
At  the  time  of  tearing  the  opening  in  the  transverse 
mesocolon  from  four  to  six  Kocher  hemostatic  forceps  are 
placed  upon  the  edge  of  the  opening  in  the  transverse 
mesocolon  at  a  uniform  distance  from  each  other.  After 
the  anastomosis  betw^een  the  stomach  and  the  jejunum 


SUEGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      439 

has  been  completed,  a  fine  silk  suture  is  passed  through  the 
wall  of  the  stomach  down  to  but  not  through  the  mucous 
membrane  or  mesocolon  from  the  suture  line  at  points 
opposite  to  those  indicated  by  the  Kocher  forceps.  The 
edge  of  the  tear  in  the  transverse  mesocolon  is  then  brought 
down  to  the  point  at  which  this  suture  has  been  placed  and 
the  latter  is  tied  about  the  small  portion  of  tissue  grasped 
by  the  Kocher  forceps.  This  is  repeated  so  that  the 
territory  in  the  transverse  mesocolon  is  held  in  apposition 
with  the  posterior  stomach- wall  at  six  points  1  mm.  from  the 
line  of  suture.  This  will  prevent  a  hernia  through  this 
opening  and  it  will  also  prevent  the  tissues  of  this  opening 
from  causing  an  obstruction  due  to  contraction  following 
the  operation,  because  union  will  take  place  between  the 
raw  surfaces  of  this  opening  and  the  posterior  wall  of  the 
stomach  immediately  after  these  sutures  have  been  tied. 
The  stomach  is  then  laid  down  in  a  normal  position,  the 
jejunum  is  replaced,  the  transverse  colon  and  the  omentum 
are  placed  over  the  jejunum  and  the  abdominal  wall  is 
closed. 

Practically  no  unnecessary  manipulation  has  been  made 
during  the  entire  operation  so  that  the  tissues  have  not 
been  bruised  and  consequently  it  is  not  likely  that  adhesions 
will  occur.  In  closing  the  abdominal  wall  great  care  is 
taken  to  evert  the  peritoneum  in  order  that  there  may  not 
be  contact  of  raw  surfaces  from  the  line  of  incision  with 
any  of  the  intraabdominal  structures.  In  this  way  a 
further  precaution  can  be  taken  against  the  formation  of 
peritoneal  adhesions. 

It  is  well  to  perform  gastric  lavage  immediately  after 
the  operation  has  been  completed,  using  normal  salt  so- 
lution at  a  temperature  of  105°  F.  in  order  to  remove  any 
mucus  and  blood  which  may  have  accumulated  in  the 


440  CANCER  OF  THE  STOMACH 

cavity  of  the  stomach.  The  warm  water  has  a  tendency 
to  stimulate  the  patient  and  to  overcome  shock  by  heat, 
and  by  the  absorption  which  will  take  place  of  a  certain 
portion  of  the  normal  salt  solution.  The  cleansing  of  the 
stomach  from  mucus  and  blood  will  prevent  the  occurrence 
of  nausea  and  vomiting  and  the  patient  will  be  greatly 
benefited  because  of  this. 

After  Treatment. — In  case  the  patient  suffers  from  nausea 
or  vomiting,  or  both,  after  the  operation,  gastric  lavage  is 
employed  at  once  in  order  to  again  relieve  the  irrita- 
tion. The  temperature  of  the  lavage  fluid  should  be 
the  same  as  that  mentioned  above.  Not  more  than  1  pint 
of  water  should  be  passed  into  the  stomach  at  one  time, 
and  then  this  should  be  evacuated  again  in  order  not  to 
overdistend  the  organ  or  place  an  unnecessary  strain  upon 
the  sutures.  Usually  it  is  not  necessary  to  perform  lavage 
more  than  once  or  twice,  but  occasionally  it  may  become 
necessary  to  repeat  gastric  lavage  several  times  a  day  for 
a  number  of  days.  In  the  meantime  the  patient  receives 
a  nourishing  enema  every  3  hours.  This  consists  of  1 
ounce  of  some  concentrated  predigested  food  dissolved  in 
3  ounces  of  normal  salt  solution,  and  is  introduced  through 
a  small  catheter  which  is  inserted  into  the  rectum  for  a 
distance  of  not  more  than  2  or  3  inches.  It  is  best  to 
attach  a  funnel  or  the  barrel  of  a  good  sized  glass  syringe 
to  the  catheter,  and  to  permit  the  fluid  to  enter  the  rectum 
by  its  own  weight.  Several  minutes  should  be  consumed 
each  time  during  the  introduction  of  this  fluid. 

In  the  meantime  it  is  well  for  the  patient  to  chew  gum 
vigorously  in  order  to  produce  saliva  whose  alkaline  re- 
action has  a  beneficial  effect  upon  the  healing  of  the 
wound  in  the  stomach.  It  will  also  prevent  the  patient 
from    suffering    from    parotitis.     The    patient    may    take 


SUEGICAL  TREATMENT  OF  CAXCER  OF  THE  STOMACH      441 

small  sips  of  very  hot  water  from  the  first  and  increase  the 
amount  constantly  from  day  to  day.  After  the  second 
day  the  patient  may  take  small  quantities  of  broth  or 
water  gruel  everj'  2  or  3  hours.  It  is  best  to  give  him  a 
half  teaspoonful  of  milk  of  magnesia  in  a  little  water  be- 
fore taking  the  gruel  in  order  that  the  stomach  may  remain 
alkaline. 

After  the  first  week  small  quantities  of  buttermilk  and 
cream  (3  parts  of  the  former  to  1  part  of  the  latter)  will  be 
borne  ver}^  well;  also  egg  albumin  in  sweet  orange  juice. 
Later  on  a  general  liquid  diet  is  permissible.  It  is  best  not 
to  begin  giving  solid  food  for  about  6  weeks.  After  the 
operation,  if  milk  is  given,  it  is  well  to  add  a  teaspoonful  of 
milk  of  magnesia  or  3^^  ounce  of  hme  water  to  4  ounces  of 
milk.  If  a  patient  is  suffering  from  constipation,  2  ounces 
of  castor  oil  may  be  given  in  the  foam  of  beer  or  malt  ex- 
tract am'  time  after  the  third  day.  Usually  the  milk  of  mag- 
nesia prevents  constipation,  however. 

EXCISION   OF  THE  PYLORIC  END   OF  THE  STOMACH  FOR  THE 
REMOVAL  OF  CANCER 

The  preparatory  treatment  is  the  same  as  that  which  has 
already  been  described.  In  planning  the  operation  it  is 
best  to  take  a  general  survey  not  only  of  the  extent  of  the 
growth,  but  also  of  the  direction  in  which  it  has  made  the 
greatest  amount  of  progress  and  the  distribution  of  lymph 
nodes  which  show  some  degree  of  enlargement.  If  these 
enlarged  lymph  nodes  extend  behind  the  stomach  into  the 
space  behind  the  duodenum  so  that  they  can  be  found 
below  the  transverse  mesocolon,  then  their  removal  is  of 
no  use.  In  many  of  these  cases  the  enlarged  lymph  nodes 
are  inflammatory  in  appearance  and  may  contain  no 
mahgnant  elements.     They  are  due  to  the  infection  from 


442  CANCER  OF  THE  STOMACH 

the  ulcerated  stomach,  the  infectious  material  having 
traveled  farther  than  the  malignant  elements.  In  cases 
then  in  which  the  cancer  is  severely  ulcerated,  the  pres- 
ence of  enlarged  lymph  nodes,  to  points  beyond  which  it 
is  safe  to  remove  these  structures,  does  not  absolutely  con- 
traindicate  the  excision  of  the  malignant  growth.  There 
is,  however,  always  a  strong  probability  that  these  glands 
contain  elements  of  the  cancer  infection  aside  from  the 
infection  due  to  other  microorganisms,  and  for  this  reason 
while  it  is  important  that  a  bad  prognosis  be  made,  under 
no  condition  should  a  hopeless  prognosis  be  given. 

We  have  patients  alive  at  the  present  time  operated 
more  than  8  years  ago  in  whom  many  of  the  greatly  enlarged 
glands  could  not  be  removed,  but  from  the  post-operative 
history  it  is  plain  that  there  were  no  malignant  elements 
present  in  these  enlarged  glands,  or  that  if  they  were  present 
they  have  since  been  destroyed.  The  latter  theory  is 
quite  as  likely  to  be  the  correct  one  as  the  former,  because 
there  can  be  no  doubt  but  that  a  large  proportion  of  the 
malignant  elements  in  every  cancer  which  are  carried  away 
from  the  original  growth  are  destroyed  and  do  not  succeed 
in  causing  secondary  growths.  By  removing  one  of  these 
lymph  nodes  and  splitting  it  through  the  center,  one  can  see 
the  little  white  areas  which  are  due  to  cancer  with  the 
naked  eye,  if  the  lymph  nodes  are  at  all  severely  infected 
with  the  malignant  growth.  So  if  there  is  any  doubt,  one 
can  satisfy  himself  very  readily.  Moreover,  the  enlarge- 
ment due  to  the  infiltration  with  cancerous  tissue  is  much 
harder  than  the  enlargement  due  to  other  infections. 
In  cases  in  which  the  lymph  nodes  are  hard  and  large  along 
the  coronary  artery,  we  have  never  seen  a  case  that  has 
permanently  recovered  after  gastrectomy,  either  partial 
or  entire.     But  it  is  theoretically  possible  for  these  glands 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      443 

also  to  be  enlarged  in  these  cases  without  containing 
cancerous  elements. 

The  next  important  point  is  to  determine  the  adhesions 
of  the  malignant  growth.  There  may  be  inflammatory 
adhesions  in  connection  with  these  growths  in  cases  in 
which  the  cancer  itself  has  not  invaded  the  surrounding 
tissues,  but  these  cases  are  not  numerous,  and  as  a  rule  if 
there  are  adhesions  the  excision  is  not  likely  to  increase 
the  life  of  the  patient.  The  liver  should  be  carefully  ex- 
amined. If  this  organ  contains  secondary  growths  the 
removal  of  the  primary  cancer  in  the  stomach  will  be  of 
no  benefit. 

In  some  cases,  there  is  an  involvement  of  the  transverse 
colon  and  this  may  be  quite  as  circumscribed  as  is  the 
involvement  of  the  pylorus.  It  is  doubtful,  however, 
whether  any  of  these  patients  can  be  permanently  cured 
by  the  removal  of  the  pyloric  end  of  the  stomach  together 
with  the  involved  portion  of  the  transverse  colon,  although 
theoretically  this  is  possible.  It  is  consequently  proper 
that  this  condition  should  be  considered  from  a  surgical 
standpoint.  After  completing  this  examination  which 
can  be  carried  out  without  traumatizing  any  of  the  tissues, 
and  without  forcing  any  of  the  cancer  infection  into  the 
lymphatics  by  manipulating  the  tissues  with  a  proper 
degree  of  gentleness  (especially  if  this  examination  is 
performed  with  the  bare  hands  without  gloves),  the  opera- 
tion should  be  selected  which  seems  most  suitable  for 
the  individual  case. 

It  is  well  to  bear  in  mind  that  violence  either  during  the 
manipulations  necessary  for  making  this  examination,  or 
during  the  operation  is  of  great  harm  and  no  benefit  to 
the  patient.  First,  because  it  greatly  increases  the  shock, 
and  second,  because  it,  undoubtedly,  serves  to  disseminate 


444  CANCER  OF  THE  STOMACH 

the  cancerous  infection.  At  this  point,  one  must  decide 
whether  it  is  best  to  make  a  gastro-enterostomy,  with  the 
plan  of  reUeving  the  obstruction  and  the  irritation  of  the 
diseased  portion  of  the  stomach,  and  improving  the  nutri- 
tion of  the  patient  during  the  remainder  of  his  Ufe,  without 
interfering  with  the  maUgnant  growth  itself,  or  whether  it 
is  best  to  perform  a  gastro-enterostomy  as  a  prehminary 
operation  with  the  plan  of  removing  the  pyloric  end  of  the 
stomach  at  a  later  operation.  The  latter  should  be  per- 
formed 2  or  3  weeks  after  the  patient  has  recovered  from 
the  traumatism  and  shock  of  the  preliminary  operation 
and  has  gained  a  little  because  of  his  improved  nutrition. 
Lastly,  whether  both  operations,  gastro-enterostomy  and 
the  excision  of  the  pyloric  end  of  the  stomach,  should  be 
performed  at  the  same  time. 

It  is  in  these  cases  in  which  experience  and  judgment  are 
of  the  greatest  value.  Both  of  these  elements  will  enable 
the  surgeon  to  reduce  the  traumatism  and  the  shock  to  a 
minimum,  and  consequently  an  experienced  surgeon  with 
good  judgment  can  perform  a  more  extensive  operation 
than  it  would  be  safe  for  a  less  experienced  surgeon  to 
undertake.  For  example,  in  a  case  in  which  it  would  seem 
proper  to  remove  the  pyloric  end  of  the  stomach  and  the 
transverse  colon  together  with  the  omentum,  the  operation 
might  last  an  hour  in  the  hands  of  a  surgeon  with  great 
experience,  while  it  would  surel}^  last  two  or  three  times  as 
long  in  the  hands  of  a  less  experienced  surgeon.  The  patient 
would  consequently  be  exposed  to  traumatism  two  or  three 
times  as  severe  in  the  latter  case.  The  exposure  of  the 
intraabdominal  organs  to  the  atmosphere  during  this 
time  would  greatly  increase  the  shock.  Many  unnecessary 
manipulations  would  be  made  by  the  latter  surgeon.  In 
most  instances,  an  inexperienced  surgeon  will  manipulate 


SUEGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      445 

tissues  more  violently,  especially  in  periods  during  which 
some  uncertainty  arises  as  to  the  best  method  of  accom- 
pUshing  certain  ends,  and  at  times  when  he  is  trying  to 
think.  During  all  of  this  time  the  patient  is  under  the 
influence  of  an  anesthetic,  the  bad  effects  of  which  increase 
greatly  with  the  length  of  time  during  which  it  is  being 
administered.  There  can  be  no  doubt  but  that  many  of 
the  deaths  following  operations  upon  the  stomach  during 
the  early  period  of  stomach  surgery  were  due  to  the  fact 
that  at  that  time  no  one  had  acquired  any  special  skill 
and  judgment  in  these  operations;  inasmuch  as  it  was 
not  possible  to  acquire  this  skill  and  judgment  except 
through  personal  experience.  The  frequency  with  which 
these  early  cases  died  from  pneumonia  was,  undoubtedly, 
due  to  unnecessary  traumatism,  to  long-continued  anes- 
thesia, and  to  long  exposure  of  the  diaphragm  and  the 
intraabdominal  tissues  to  this  unnecessary  irritation  and, 
of  course,  also  to  the  fact  that  these  patients  were  placed 
in  bed  in  a  horizontal  position  instead  of  having  the  upper 
end  of  the  body  elevated  after  the  operation. 

Having  then  considered  all  of  the  conditions  present, 
together  with  the  elements  connected  with  the  individual 
patient,  the  further  steps  of  the  operation  must  be  chosen. 
If  it  seems  wise  to  make  an  excision  of  the  pyloric  end  of 
the  stomach,  the  question  will  arise  as  to  whether  it  is 
best  to  perform  a  gastro-enterostomy  first  or  whether  it  is 
better  to  make  an  excision  and  later  make  the  gastro- 
enterostomy. Theoretically,  both  plans  are  equally  good 
so  that  this  may  be  left  to  the  individual  incUnation  of 
the  operator.  If  the  gastro-enterostomy  is  performed  first, 
the  method  which  has  ah-eady  been  described  should  be 
followed.  If  the  excision  of  the  pylorus  is  made  first,  there 
remains  a  choice  between  making  a  posterior  gastro-enteros- 


446  CANCER  OF  THE  STOMACH 

tomy  or  using  a  portion  of  the  end  of  the  stomach  for  the 
pui-pose  of  making  this  anastomosis.  Both  of  these 
methods  will  be  described  later. 

Excision  of  the  Pyloric  End  of  the  Stomach. — If  one  bears 
in  mind  the  blood  supply  of  the  stomach,  it  is  an  easy  matter 
to  excise  the  pyloric  end  \\-ithout  the  loss  of  more  than  a 
few  drams  of  blood.  This  is  because  the  blood  supply 
comes  from  f om*  definite  points :  the  coronar\^  arters-  above  to 
the  left,  the  pjdoric  artery  above  to  the  right,  the  gastro- 
epiploic arterj^  to  the  right  and  left  below.  If  these  four  points 
are  grasped  between  two  paks  of  forceps  at  each  point  and  cut 
and  ligated  immediately, "the  principal  blood  supply  of  the 
portion  to  be  removed  is  completely  under  control.  Com- 
municating branches  of  blood-vessels  are  then  controlled 
by  the  apphcation  to  the  greater  and  lesser  omenta  of 
strong  hemostatic  forceps  placed  in  pairs,  the  intervening 
tissue  being  cut  and  the  distal  portion  being  carefully 
Ugated.  A  sufficient  amount  of  the  lesser  and  greater 
omentimi  is  permitted  to  project  beyond  the  hgation  to 
make  sUpping  impossible.  These  vessels  may  be  Ugated 
with  catgut  or  fine  silk.  In  this  way,  the  portion  of  the 
stomach  to  be  removed  is  entirely  separated  from  its  at- 
tachment from  the  greater  and  lesser  omenta.  It  should 
include  all  of  the  tissues  containing  enlarged  hmiph  nodes, 
and  in  earl}^  cases  it  should  extend  up  to  the  coronary 
arteries  and  in  late  cases  bej^ond  these  arteries.  On  the 
side  of  the  duodenum,  the  forceps  should  be  applied  to  a 
point  at  least  3  cm.  beyond  the  pyloric  end  of  the  malignant 
growth,  but  even  in  cases  in  which  the  growth  does  not 
approach  the  pylorus,  the  excision  should  still  include 
this  structm-e,  because  recurrence  is  not  uncommon  in  the 
tissues  belonging  to  the  pylorus,  while  it  almost  never 
occm's  in  the  tissues  belonging  to  the  duodenum. 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      447 

If  there  are  inflammatory  adhesions  to  the  pancreas 
these  are  removed  with  great  care  in  order  to  prevent  injmy 
to  the  pancreatic  tissues.  If  the  tumor  extends  into  the 
pancreas  a  portion  of  this  organ  may  be  removed,  but  inas- 
much as  there  have  been  no  permanent  recoveries  in  our 


Fig.  96. — Resection  of  two-fifths  of  tlie  stomach  for  carcinoma  at  the 
lesser  curvature  with  posterior  gastro-jejunostomy  (A)  made  as  close  as 
possible  to  the  line  of  excision  of  the  stomach.  The  anterior  layer  of  the 
greater  omentum  has  been  divided  close  to  the  greater  curvature  and  the 
pylorus  has  been  doubly  clamped  and  sectioned.  Portion  to  be  excised 
delimited  by  dotted  lines. 

experience  in  any  of  these  cases,  it  is  doubtful  whether  the 
additional  danger  to  the  life  of  the  patient  caused  by  cutting 
into  the  pancreas  will  be  compensated  for  by  the  proba- 
bility of  the  permanency  of  a  cure. 

The  entire  portion  of  the  stomach  containing  the  cancer, 
together  with  at  least  3  cm.  of  apparently  normal  tissue  in 


448 


GANGER   OF   THE    STOMACH 


the  direction  of  the  duodenum  including  the  pylorus  and 
at  least  6  cm.  toward  the  cardiac  end  of  the  stomach  of 
apparently  normal  tissue  is  in  this  manner  entirely  loosened 
from  all  surrounding  tissues. 

Especial  attention  should  be  directed  toward  the  import- 
ance of  preventing  injury  to  the  arteries  supplying  the 
transverse  colon.  In  order  that  the  latter  viscus  may  not 
become  necrotic  as  a  result  of  interference  with  its  blood 
supply,  a  strong  stomach  clamp  is  next  applied  to  the 


X^ajje^naitt 


Fig.  97. — Excision  of  pylorus  and  antrum  of  stomach  with  end-to-side 
gastrojejunostomy  for  multiple  malignant  ulcers  just  proximal  to  the 
pylorus.  Dotted  line  shows  projected  line  of  excision.  Clamps  in  posi- 
tion for  section  of  pjdorus. 


upper  end  of  the  duodenum.  A  second  clamp  is  applied 
to  the  stomach  at  a  point  chosen  for  resection,  then  two  other 
clamps  are  apphed  to  keep  the  contents  of  the  portion  to 
be  removed  from  soiHng  the  peritoneal  cavity  when  the 
portion  is  cut  away.  The  intervening  portion  is  then 
removed  by  cutting  along  the  edge  of  the  two  clamps  which 
were  apphed  first. 

The  treatment  of  the  two  stumps  must  now  be  considered. 
If  enough  of  the  duodenal  end  is  left  to  invert  the  cut  end 
of  this  structure,  this  may  be  accomplished  in  various 
ways.     A  purse-string  suture  of  silk  or  linen  should  be 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      449 


applied  1  cm.  below  the  clamp  and  the  crushed  end  should 
be  inverted  into  the  lumen  of  the  duodenum  while  this 
purse-string  suture  is  being  tied.  The  surface  which  has 
been  puckered  in  by  the  tying  of  this  suture  is  then  covered 
by  the  use  of  two  rows  of  interrupted  Lembert  sutures  of 
silk  or  hnen,  care  being  taken  not  to  leave  any  portion 
which  is  not  covered  with  peritoneum.     A  gauze  pad  is 


Fig.  98. — Shows  method  of  mverting  stump  of  duodenum. 

then  laid  over  this  surface  while  the  stump  of  the  stomach 
is  being  disposed  of.  It  seems  to  be  a  good  practice  to 
cauterize  the  portion  of  the  stomach-wall  grasped  in  the 
heavy  clamps  with  the  actual  cautery.  A  strong,  silk  or 
linen  suture  or  a  fine,  double,  chromicized  catgut  suture  is 
then  used  to  fold  in  the  portion  of  the  stomach-wall  which 
has  been  crushed  into  the  lumen  of  the  stomach  by  placing 
Lembert  sutures,  grasping  the  tissues  on  each  side  of  the 

29 


450  CANCER    OF   THE    STOMACH 

clamps  successively  and  passing  them  over  the  clamps 
passing  throughout  the  distance  until  the  entu'e  defect 
has  been  covered  with  these  sutures.  Then  the  clamps  are 
loosened  and  the  continuous  sutures  are  tightened.  This 
causes  the  crushed  portion  to  fold  into  the  lumen  of  the 
stomach,  while  the  serous  surfaces  on  the  two  sides  come 
into  accurate  apposition.  An  additional  stitch  is  added  at 
the  end  of  this  line  of  sutures  for  the  purpose  of  tying  the 
free  end  upon  which  traction  has  been  made  to  bring  the 
surfaces  in  apposition.  It  is  important  to  fold  in  the 
corners  carefully  with  additional  sutures,  because  these 
points  represent  the  weak  points  in  the  closure.  A  fine  silk 
Lembert  suture  is  then  placed  over  the  entire  line  of  these 
deep  sutures  to  serve  as  a  provision  for  safety  in  case  some 
one  of  the  stitches  might  not  be  absolute!}^  reHable. 

We  now  have  the  stomach  entirely  separated  from  the 
intestine  and  it  becomes  necessary  to  make  a  gastro-jejun- 
ostomy  in  order  to  reunite  these  structures.  It  is  best  to 
do  this  on  the  posterior  surface  of  the  remaining  portion 
of  the  stomach  at  a  suflB.cient  distance  from  the  sutm^e  Hne 
just  described,  to  insure  a  satisfactory  blood  supply  so 
that  there  may  be  a  rapid  and  perfect  union  between  the 
stomach  and  the  intestine.  It  is  well  to  thoroughly  irri- 
gate the  portion  of  the  stomach  with  normal  salt  solution 
at  105°  F.  before  this  last  step  is  carried  out.  If  there  is 
any  doubt  about  the  safety  of  using  the  gastro-enterostomy 
clamps  which  were  used  in  the  gastro-enterostomy  opera- 
tion described  above,  then  the  operation  can  be  performed 
without  clamps  quite  as  conveniently  as  with  them.  A 
loop  of  the  jejunum  just  below  the  transverse  mesocolon 
is  placed  in  the  same  relative  position  that  w^as  described  in 
the  gastro-enterostomy  operation  above,  then  the  posterior 
serous  suture  is  applied,  uniting  the  jejunum  to  the  pos- 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      451 

terior  surface  of  the  stomach  for  a  distance  of  5  cm.  These 
sutures  should  grasp  all  the  tissues  down  to  the  mucous 
membrane  but  not  through  this  tissue.  An  incision  4  cm. 
long  is  then  made  parallel  to  and  K  cni.  from  this  row  of 
sutures  extending  down  to  the  mucous  membrane  but  not 
through  it,  both  on  the  stomach  and  the  small  intestine.  A 
fine,  double,  chromicized  catgut  thread  in  an  ordinary 
sewing  needle  is  then  passed  through  all  the  layers  of  the 


^•*t^  ''  -  -^  -3Nfe^^>5t  t  "355^^^. 


Fig.  99. — -Showing  the  anterior  Connell  catgut  stitcli. 

stomach  and  the  intestine.  The  line  of  sutures  is  begun  at 
the  point  at  which  the  silk  suture  was  ended  and  carried  to 
the  point  at  which  the  silk  suture  was  begun. 

The  mucous  membrane  is  then  cut,  care  being  taken  to 
first  place  moist  gauze  bands  around  the  tissues  so  as  to 
prevent  soihng  of  the  peritoneal  cavity.  Any  substance 
which  may  come  from  the  cavity  of  the  intestine  and  the 
stomach  is  carefully  sponged  away  and  then  the  catgut 
suture  is  continued  around  the  remaining  portion  of  the 


452 


CANCER    OF   THE    STOMACH 


opening.  The  Connell  suture  is  employed  for  this  purpose. 
It  is  appUed  in  the  following  manner.  The  suture  is 
passed  through  the  layers  of  the  stomach  wall  from  within 
outward,  then  carried  over  to  the  wall  of  the  intestine, 
passed  through  all  the  layers  from  without  inward,  then 
from  within  outward  and  then  it  is  carried  across  to  the 
stomach  again.     These  steps  are  repeated  until  the  entire 


Fig.  100. — Showing  method  of  closure  of  end  of  the  stomach  by  a  Connell 
line  of  catgut  sutures  which  is  then  covered  with  a  row  of  Lembert  silk 

sutures. 

opening  is  closed,  care  being  taken  to  remain  within  2  mm. 
from  the  edge  of  the  wound.  As  these  sutures  pass  through 
all  of  the  layers,  there  can  be  no  hemorrhage  from  the 
edges  of  the  incision.  The  catgut  suture  is  then  tied  to  the 
end  which  was  left  long  at  the  beginning.  It  is  well  to  oil 
the  catgut  suture  with  vaseline  so  as  to  have  it  perfectly 
smooth  in  order  that  it  may  not  tear  the  tissues  as  it  passes 
through  them. 


SUEGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      453 

The  original  silk  suture  is  now  taken  up  again  and  is 
carried  on  in  the  form  of  a  Lembert  suture  around  the 
anterior  surface  of  the  anastomosis  to  the  point  of  its 
beginning  where  it  is  tied  to  the  end  which  was  left  at  the 
beginning  of  this  suture.  The  edges  of  the  opening  in  the 
transverse  mesocolon  are  now  sutm'ed  to  the  stump  of  the 


^ 


,  I  /j  f  I'll 


^^,^ 


'/  '  y^fi'y] 


\   "A.' 


)   h 


Fig.  101. — The  greater  omentum  sutured  with  intermpted  silk  stitches 
to  the  stomach  and  lesser  omentum.  Dotted  lines  indicate  cut  end  of 
stomach  and  the  anastomosis. 

stomach  and  the  entire  surface  left  bare  hy  the  removal  of 
the  pyloric  end  of  the  stomach  is  covered  by  uniting  the 
greater  and  lesser  omenta,  or  by  carr^dng  the  stump  of  the 
duodenum  up  to  the  stump  of  the  stomach  and  uniting 
these  by  means  of  fine  silk  sutures.  At  all  events,  every 
portion  of  the  raw  surface  must  be  carefully  covered  with 
peritoneum. 


454  CANCER  OF  THE  STOMACH 

In  some  cases  the  amount  of  available  tissue  for  closing 
the  duodenum  is  not  so  plentiful  as  might  be  desired  to 
obtain  a  closure  in  whose  permanency  one  can  have 
complete  confidence.  In  such  cases  it  is  best  to  provide 
for  the  possible  occurrence  of  a  leakage  some  days  after 
the  operation.  By  carrying  one  or  two  cigarette  drains  down 
to  the  closed  end  of  the  duodenum,  passing  these  out  of  the 
upper  end  from  the  abdominal  wound  one  can  provide  for 
this  comphcation.  These  cigarette  drains  are  constructed 
by  roUing  a  pad  of  gauze  within  a  piece  of  rubber  tissue  so 
that  the  rubber  tissue  overlaps  the  gauze.  The  end  of  the 
gauze  should  project  a  httle  from  each  end  of  the  rubber 
tissue.  It  may  be  well  to  add  to  this  a  glass  drainage  tube 
which  will  serve  to  keep  the  abdominal  wound  sufficiently 
open  to  permit  any  accumulations  to  pass  out  of  the 
wound. 

In  case  the  cancer  involves  the  pylorus  so  that  it  will 
become  necessary  to  remove  2  or  3  cm.  or  more  of  the 
upper  end  of  the  duodenum,  it  is  often  better  to  utihze  a 
rubber  drainage  tube  30  cm.  long  and  1  cm.  in  diameter, 
and  to  draw  over  this  a  second  rubber  drainage  tube  just 
large  enough  to  prevent  the  inner  drainage  tube  from 
slipping  through  the  outer  one  unless  quite  a  little  force 
is  appUed.  The  outer  drainage  tube  should  have  the  length 
of  15  cm.  so  that  the  inner  tube  projects  bej'ond  it  at  each 
end  about  7>9  cm.  At  one  end  the  inner  tube  should  have 
a  number  of  small  perforations;  this  end  should  then  be 
inserted  into  the  duodenum  for  a  distance  of  15  cm.  and 
the  free  end  of  the  duodenum  should  be  closed  by  means  of 
several  purse-string  sutures  about  this  drainage  tube  so  as 
to  make  a  complete  closure  and  so  as  to  guard  against 
leakage.  The  serous  surface  should  be  inverted  and  after 
three  or  four  purse-string  sutin*es  have  been  applied,  the 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH   455 

edge  of  the  duodenum  should  be  sutured  by  means  of  from 
four  to  six  fine,  silk  sutures  to  the  outer  rubber  tube.  Then 
this  should  be  carried  out  of  the  upper  angle  to  the  abdominal 
wound  or  through  a  small  stab  wound  at  a  point  directly 
in  front  of  the  end  of  the  duodenum.  It  is  possible  for  bile 
and  duodenal  secretion  to  escape  through  this  tube  and,  on 
the  other  hand,  one  may  introduce  into  the  duodenum 
through  this  tube  a  quantity  of  normal  salt  solution  by  the 
drop  method,  to  which  some  form  of  concentrated  food  has 
been  added.  Adhesions  will  take  place  between  the  end 
of  the  duodenum  and  the  abdominal  wall,  and  after  1  or  2 
weeks  the  sutures  holding  the  rubber  tubing  in  place  will  cut 
through  the  edge  of  the  duodenum  by  causing  pressure- 
necrosis  and  then  the  walls  of  the  duodenum  will  close 
spontaneously.  Occasionally,  considerable  quantities  of 
bile  and  pancreatic  fluid  will  escape  through  the  wound  and 
this  may  cause  excoriation  of  the  skin.  This,  however,  can 
be  readily  corrected  by  giving  the  patient  the  white  of  one 
egg  every  2  hours  night  and  day  for  several  days  and 
by  covering  the  raw  surface  freely  with  white  vaseline  or 
with  castor  oil.  The  ingestion  of  egg  albumin  seems  to 
prevent  the  formation  of  this  irritating  secretion.  In 
patients  who  are  very  much  depressed  as  a  result  of  their 
disease  and  the  operation,  it  is  wise  to  treat  the  end  of  the 
duodenum  in  this  way,  because  this  enables  one  to  supply 
the  necessary  amount  of  nourishment  almost  immediately 
after  the  operation  without  in  any  way  interfering  with  the 
healing  of  the  gastroenterostomy  wound.  Usually  it  is 
better  to  pass  this  duodenal  rubber  tube  out  through  a 
separate  opening  and  to  suture  the  stump  of  the  duodenum 
by  means  of  a  few  fine,  silk  sutures;  thus  one  can  provide  an 
additional  safeguard  against  soiling  of  the  peritoneal 
cavity  with  fluid  coming  from  the  duodenum.     The  closure 


456  CANCER  OF  THE  STOMACH 

of  the  end  of  the  duodenum  about  the  rubber  tubing  should, 
however,  be  so  complete  that  leakage  cannot  occur  for  a 
considerable  period  of  time.  By  that  time  adhesions  will 
have  formed  which  will  protect  the  general  peritoneal 
cavity.  It  is,  of  course,  of  the  greatest  possible  importance 
thi'oughout  this  operation  that  at  no  point  will  there  be 
tension  upon  any  of  the  tissues  because  all  of  the  tissues 
are  so  dehcate  that  the  sutures  may  not  hold  if  subjected 
to  tension.  By  carefully  bearing  in  mind  this  additional 
principle,  one  can  invariably  provide  some  means  of  avoiding 
such  difficulty.  Of  course,  the  smaller  the  amount  of 
tissue  which  it  is  necessary  to  remove  in  the  individual 
case,  the  less  the  danger  from  tension  upon  the  sutures,  but 
even  in  cases  in  which  a  very  large  amount  of  the  stomach 
has  been  removed,  it  is  possible  to  guard  against  this 
difficulty.  Under  no  condition  should  any  suspicious 
tissue  be  left  in  order  to  prevent  tension.  One  can  always 
improvise  some  other  means  of  accomphshing  this  end. 

COMPLETE  GASTRECTOMY 

From  a  technical  standpoint,  a  complete  gastrectomy  is 
but  sHghtly  more  difficult  than  is  the  operation  which  has 
just  been  described.  From  a  practical  standpoint,  on  the 
other  hand,  the  operation  may  be  looked  upon  as  almost,  if 
not  entirely  useless,  not  because  of  the  difficulty  of  the 
operation  itseK,  but  because  of  the  fact  that  in  cases  in 
which  the  operation  can  be  performed  with  permanent 
success,  it  is  not  required,  because  success  can  be  obtained 
by  means  of  the  simpler  operation  which  has  just  been 
described.  On  the  other  hand,  in  cases  in  which  complete 
gastrectomy  is  the  only  operation  which  gives  any  possi- 
bihty  of  permanent  success,  there  are  practically  always 
comphcations  which  will  make  it  either  impossible  for  the 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      457 

patient  to  recover  permanently  from  the  operation  or 
certain  that  recurrence  will  cause  the  death  of  the  patient 
in  a  relatively  short  time. 

There  are  certain  advertising  advantages  in  performing  a 
complete  gastrectomy,  occasionally,  because  no  matter 
how  carefully  one  guards  the  secret  of  having  performed 
such  an  operation,  it  is  certain  to  be  carried  from  mouth 
to  mouth  until  the  surgeon  who  has  performed  it  gains  a 
certain  degree  of  notoriety  for  unusual  surgical  skill. 
But  so  far  as  the  patient  is  concerned,  it  is  doubtful  whether 
in  any  case  in  which  the  operation  was  necessarj^,  he  had 
secured  any  real  benefit. 

Operative  Technique  for  Gastrectomy. — The  technique 
described  in  the  previous  operation  will  also  serve  for  the 
operation  of  complete  gastrectomy  with  the  exception 
that  the  entire  stomach  is  laid  bare  instead  of  only  its 
pyloric  end.  This  is  done  by  applying  artery  forceps 
behind  the  entire  greater  and  lesser  curv^ature  to  a  point 
within  3  or  4  cm.  of  the  esophagus.  Stomach  clamps  are 
then  apphed  as  in  the  previous  operation,  with  the  excep- 
tion, however,  that  the  clamp  nearest  the  esophagus  must  be 
apphed  in  such  a  direction  that  the  stump  which  is  left 
above  it  is  suflacient  to  permit  its  attachment  to  a  loop  of 
the  jejunum.  The  esophagus  and  small  remnant  of  the 
stomach  are  then  thoroughlj^  irrigated  with  normal  salt 
solution  through  a  stomach  tube  which  has  previously 
been  inserted  into  the  stomach  and  has  been  withdrawn 
within  a  point  just  above  the  apphcation  of  the  upper 
clamp.  All  of  the  Uquid  must  be  siphoned  out  carefully  so 
that  none  of  it  remains  in  the  esophagus  or  the  httle  rem- 
nant of  stomach  and  so  causes  soiUng.  The  portion  of  the 
stomach  between  the  two  clamps  is  then  removed  in  the 
manner  described  in  the  pre\dous  operation.     The  end  of 


458  CANCER    OF   THE    STOMACH 

the  duodenum  is  treated  after  the  method  which  has  just 
been  described  by  inserting  the  double  drainage  tube  so 
that  there  can  be  no  pressure  of  fluid  from  the  duodenum 
upon  the  jejunum. 

A  loop  of  the  jejunum,  sufficiently  long  to  be  carried  up 
to  the  stump  of  the  stomach  without  tension,  is  passed 
through  an  opening  in  the  transverse  mesocolon,  or  it  may 
be  passed  in  front  of  the  transverse  colon.  A  longitudinal 
incision  is  made  in  this  loop  at  its  upper  end.  This  in- 
cision should  be  5  cm.  long  and  the  edge  of  the  opening 
carefully  sutured  to  the  stump  of  the  remnant  of  the 
stomach,  one  suture  grasping  all  of  the  layers  with  the 
exception  of  the  peritoneum,  and  a  second  row  of  Lembert 
sutures  grasping  all  the  layers  down  to,  but  not  through, 
the  mucous  membrane.  It  is  absolutely  necessary  that 
there  should  be  no  tension.  The  edge  of  the  opening  in 
the  transverse  mesocolon  is  then  carefully  sutm^ed  about 
the  duodenum.  The  entire  defect  in  the  peritoneum  caused 
by  the  removal  of  the  stomach  must  be  covered  by  uniting 
the  edges  of  the  greater  and  lesser  omenta. 

In  these  cases  it  is  well  to  place  a  glass  drainage  tube  and 
one  or  two  cigarette  drains  down  to  the  space  from  which 
the  stomach  has  been  removed,  in  order  that  any  hquid 
which  may  accumulate  will  be  carried  away  from  the 
peritoneal  cavity.  In  these  cases  it  is  best  to  pass  the 
rubber  drainage  tube  entering  the  duodenum  through  a 
separate  stab-wound,  in  order  that  the  distance  between 
the  end  of  the  duodenum  and  the  abdominal  wall  may 
be  as  small  as  possible  so  that  the  peritoneum  about  the 
stab-wound  may  be  sutured  to  the  duodenum. 

If  there  is  any  doubt  about  the  safety  of  the  suture  line 
between  the  stump  of  the  stomach  and  the  jejunum,  this 
may  be  strengthened  by  suturing  over  it  a  piece  of  omentum 


SUEGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      459 

or  a  strip  of  fascia  lata  3  era.  wide  and  long  enough  to 
encircle  the  gastro-enterostomy  without  causing  any 
compression. 

The  after-treatment  in  these  cases  is  the  same  as  in  the 
case  just  described.  A  small,  soft-rubber  tube  may  be 
carried  through  one  nostril  and  down  through  the  esophagus 
and  the  remnant  of  the  stomach  into  the  jejunum  so  that 
the  end  extends  for  a  distance  of  15  to  30  cm.  into  the 
jejunum.  Through  this  tube  small  quantities  of  pre- 
digested  food  may  be  introduced  into  the  intestine  every 
2  hours.  Water  may  also  be  given  through  this  tube. 
It  is  well  to  administer  liquid  nourishment  by  rectum  in 
the  form  of  nourishing  enemata  every  3  hours  in  order 
to  support  the  patient  as  well  as  possible;  normal  salt  solu- 
tion may  be  given  by  the  drop  method. 

In  case  the  flow  of  bile  and  pancreatic  fluid  does  not  be- 
come estabhshed  normally  through  the  loop  of  the  jejunum 
which  has  been  carried  up  to  the  stump  of  the  stomach,  it 
may  become  necessary  later  on  to  plan  an  entero-enter- 
ostomy  between  the  two  branches  of  the  jejunum.  This 
can  best  be  done  at  a  point  from  3  to  5  cm.  beyond  the 
transverse  mesocolon.  This  can  be  accompUshed  by  the 
application  of  a  Murphy  button  or  by  performing  an 
anastomosis  3  cm.  in  length  after  the  method  described  for 
performing  anastomosis  between  the  stomach  and  the 
jejunum. 

GASTRO-ENTEROSTOMY  'FOLLOWING  PARTIAL  GASTRECTOMY 

BY  UNITING  THE  JEJUNUM  DIRECTLY  TO  THE  LOWER  END 

OF    THE    STOMACH    WOUND 

Some  surgeons  with  great  experience  in  intestinal  surgery 
prefer  to  make  the  partial  excision  of  the  stomach  first 
and  then  to  make  the  anastomosis  between  the  remaining 
portion  of  the  stomach  and  the  jejunum  directly  to  the 


460  QANCER  OF  THE  STOMACH 

lower  end  of  the  wound  remaining  in  the  stomach.  In 
performing  this  operation  there  is  great  danger  of  leakage 
at  the  point  at  which  the  jejunum  is  united  with  the  suture 
line  of  the  stomach.  It  is  necessary  to  bring  the  opening 
in  the  stomach  down  to  the  opening  in  the  jejunum,  but 
if  this  leakage  is  guarded  against  by  the  proper  applica- 
tion of  sutures  at  this  point,  the  total  amount  of  trau- 
matism required  by  the  operation  is  considerably  less 
than  if  the  operation  is  performed  which  has  already  been 
described.  But  it  must  be  borne  in  mind  that  it  requires  a 
much  greater  amount  of  technical  skill  to  execute  this 
operation  than  the  one  which  has  been  described. 

Technique  of  Operation. — The  technique  of  the  opera- 
tion is  exactly  the  same  as  in  the  previous  operation. 
After  the  clamps  have  been  applied  the  remnant  of  the 
stomach  is  carefully  irrigated  and  all  of  the  liquid  is 
siphoned  out.  Then  a  pad  is  placed  behind  the  stomach; 
the  portion  of  the  stomach  to  be  sacrificed  is  cut  away 
and  fine-toothed  clamps  are  applied  to  the  edge  of  the 
remnant  of  the  stomach  grasping  all  of  its  layers.  If 
there  is  a  bleeding  point,  this  is  caught  and  a  fine,  silk 
suture  is  passed  through  the  wall  of  the  stomach  to  com- 
press the  bleeding  vessel.  The  cavity  of  the  remaining 
portion  of  the  stomach  is  carefully  sponged  until  it  is 
perfectly  dry  and  then  a  suture  is  applied  uniting  both 
wound  edges  together  sufficiently  far  from  the  greater 
curvature  of  the  stomach  to  determine  the  size  of  the 
opening  which  must  remain  for  the  purpose  of  making  an 
anastomosis  with  the  opening  in  the  jejunum.  It  is  im- 
portant to  determine  this  at  this  stage,  because,  otherwise, 
almost  invariably  the  opening  is  left  too  small.  All  of  the 
layers,  with  thie  exception  of  the  peritoneal  surface,  are 
united  by   means  of  a   continuous  suture,  or  in  case  the 


STEGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      461 


remnant  of  the  stomach  is  of  considerable  size,  a  ConneU 
suture  may  be  used  for  this  purpose.  This  passes  from 
the  mucous  membrane  out  through  aU  of  the  layers  2 
mm.  from  the  edge  of  the  wound,  then  across  to  the  other 
side  and  through  all  of  the  layers  from  without  inward. 
The  sutm'e  is  then  tied  witliin  the  stomach  waU,  then  it 
is  carried  out  through  one  edge  and  across  the  wound,  then 
from  without  inward  and  from  witliin  outward  on  the 


Fig.  102. — The  duodenum  lias  been  inverted  and  the  lower  portion  of 
the  stomach  reflected  upward.  A  loop  of  jejunum  has  been  brought  through 
the  opening  iu  the  trans^-erse  mesocolon  and  point  {A)  sutured  to  the 
stomach. 

other  side,  then  across  to  the  other  side,  then  from  without 
inward  and  from  within  outward  and  across  again  and 
so  on  until  the  entire  wound  has  been  closed,  especial  care 
being  taken  to  fold  in  the  angle  of  the  upper  end.  A.  row 
of  Lembert  sutures  is  now  placed  over  this  suture  line  so 
that  the  peritoneum  is  once  more  united.  The  opening 
at  the  lower  end  of  the  stomach  wound  is  then  sutured 
into  a  wound  of  exactly  the  same  size  made  in  the  jejunum 


462 


CANCER   OF   THE    STOMACH 


at  the  point  just  below  the  transverse  mesocolon  tnrough 
which  an  opening  has  been  torn. 

The  union  between  this  opening  in  the  stomach  and  that 
in  the  jejunum  is  accomplished  by  two  rows  of  sutures,  the 
first  grasping  all  of  the  layers  with  the  exception  of  the 
peritoneum,  the  latter  consisting  of  a  row  of  Lembert 
sutures  of  fine  silk  completely  covering  the  first  row  of 
sutures.     From  three  to  six  additional  sutures   are  now 


JejTziunB. 


Fig.  103. — Showing  method  of  beginning  anastomosis  of  end  of  stomach  to 

side  of  jejunum. 

placed  at  the  point  at  which  the  jejunum  is  opposite  the 
suture  line  which  is  closed  by  the  upper  end  of  the  stomach 
wound.  It  is  important  that  these  sutures  be  applied  with 
great  accuracy  in  order  that  there  may  be  no  leakage  at 
this  point. 

The  opening  in  the  transverse  mesocolon  is  then  sutured 
to  the  wall  of  the  stomach  7  mm.  from  the  gastro-enterostomy 
opening  by  means  of  six  or  eight  fine  silk  sutures.     The  ab- 


SURGICAL  TREATMENT  OF  CANCER  OE  THE  STOMACH      463 

dominal  wall  is  then  closed.     The  jejunum  is  treated  as 
in  the  previous  operations. 

If  this  operation  is  performed  with  great  skill,  it  has 
the  advantage  of  placing  the  gastro-enterostomy  opening 
at  the  lowest  point  of  the  stomach  and  of  providing  a 
mechanical  arrangement  which  is  ideal.     Were  it  not  for 


Fig.  104. — -The  Connell  line  of  suture  being  applied.     A  row  of  Lembert 
silk  sutures  later  surrounds  this. 

the  great  likelihood  of  faulty  union  at  the  one  point,  this 
operation  would  undoubtedly  be  the  operation  of  choice. 


POST-OPERATIVE  TREATMENT 

It  is  important  to  carry  out  a  definite  plan  of  post- 
operative treatment  in  these  cases  in  order  to  prevent 
avoidable  deaths.  During  the  early  times  of  gastric 
surgery,  there  were  many  deaths  from  pneumonia  and 
quite  a  number  from  acute  dilatation  of  the  stomach. 
The  deaths  from  pneumonia  were  due  to  a  great  extent  to 
unnecessary  traumatism   during  the   operation,   to   infec- 


464  CANCER  OF  THE  STOMACH 

tion  during  operation  and  to  anesthesia  which  was  pro- 
longed unnecessarily  because  of  the  incompetency  and 
inexperience  of  the  surgeon  and  to  lack  of  judgment. 
These  causes  of  pneumonia  have  now,  fortunately,  been 
eliminated  because  surgeons  can  now  obtain  skill  by  assist- 
ing those  who  have  a  vast  experience. 

Another  cause  of  pneumonia  came  from  aspiration  of 
vomitus.  This  is  ehminated  now  by  performing  gastric 
lavage  at  the  close  of  the  operation  and  again  whenever 
there  is  any  sign  of  nausea.  Another  cause  consisted  in 
the  tendency  to  hypostatic  congestion  of  the  lungs  by  plac- 
ing the  patient  in  the  horizontal  recumbent  position  directly 
after  the  operation  while  the  patient  was  still  deeply 
narcotized,  due  to  the  fact  that  the  anesthetic  was  con- 
tinued until  the  close  of  the  operation.  By  permitting  the 
patient  to  awaken  thoroughly  by  the  time  the  last  stitches 
are  inserted  this  cause  is  also  eliminated,  and  by  elevating 
the  head  of  the  bed  18  inches  and  placing  pillows  under 
the  patient's  head  and  shoulders  when  he  returns  to  bed 
and  permitting  him  to  move  about,  the  tendency  to  hypo- 
static congestion  of  the  lungs  is  eliminated.  As  a  result 
of  these  changes  the  percentage  of  cases  of  pneumonia 
following  operations  upon  the  stomach  has  been  enor- 
mously reduced  so  that  we  now  practically  never  see  a  case 
of  this  kind. 

Acute  Post -operative  Dilatation  of  the  Stomach. — 
From  some  mechanical  condition  which  happens  occasion- 
ally after  operations  upon  the  stomach  and  gall-bladder,  the 
patient  suffers  from  an  acute,  very  rapid  dilatation  of 
the  stomach  which  may  result  in  so  marked  a  displace- 
ment of  the  heart  that  it  may  prove  fatal.  It  may  also 
cause  a  rupture  of  the  suture  hne  between  the  stomach 
and  the  intestine.     Since  we  have  systematically  practised 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      465 

gastric  lavage  at  the  close  of  these  operations,  we  have  not 
encountered  this  compUcation.  It  is,  however,  important 
to  bear  the  possibihty  of  this  condition  in  mind  and  to 
introduce  a  stomach  tube  immediately  in  case  this  com- 
pUcation occurs.  This  should  be  followed  by  careful 
gastric  lavage  with  normal  salt  solution  at  105°  F.  This 
should  be  repeated  in  case  any  SAToiptoms  recur. 

The  condition  can  be  recognized  by  the  shortness  of 
breath,  by  the  sudden  increase  in  pulse  rate  and  by  the 
complaint  of  the  patient  that  he  is  being  smothered.  Phys- 
ical examination  will  show  a  marked  displacement  of  the 
left  lung  and  heart.  It  is  important  to  act  quickly  in  these 
cases  because  death  sometimes  occurs  within  an  hour  of 
the  beginning  of  the  dilatation.  It  is  consequently  wise 
to  instruct  the  nurse  to  perform  lavage  whenever  there  is 
any  doubt.  Small  sips  of  water  may  be  given  to  these 
patients  almost  immediately  after  the  operation.  Patients 
receive  much  comfort  from  the  chewing  of  gum,  because 
the  saliva  which  they  are  able  to  swallow  keeps  the  stomach 
in  an  alkahne  condition  and  overcomes  the  severe  thirst 
which  is  further  controlled  by  the  free  administration  of 
water  by  rectum  by  the  drop  method.  It  is  quite  as  weU 
to  use  water  as  normal  salt  solution  by  rectum  in  these 
cases.  The  injection  of  water  should  be  continued  very 
slowly,  but  ver^^  constantly  so  long  as  it  is  being  absorbed, 
then  this  should  be  interrupted  for  2  full  hours  in  order 
to  give  the  intestine  an  opportunity  to  secure  rest.  It  is 
best  to  measure  the  amount  the  patient  can  take  com- 
fortably in  this  manner  in  order  that  a  quantity  slightly 
less  than  this  may  be  given  during  the  next  proctoclysis. 
Thus  this  may  be  interrupted  before  the  patient's  hmit 
has  been  reached.  For  instance,  if  a  patient  can  take 
1,000    cc.    of    water   by   rectum   before   feeUng   any  dis- 


466  CANCER  or  the  stomach 

comfort  during  the  first  administration,  only  900  cc. 
or  about  30  ounces  should  be  given  during  the  second 
administration,  always  with  an  interval  of  2  hours.  It 
will  be  found  that  the  saliva  will  flow  much  more  copiously 
during  the  chewing  of  the  gum  after  the  patient  has  had 
one  or  more  of  these  proctoclyses. 

Aside  from  increasing  the  comfort  of  the  patient,  the 
chewing  of  gum  prevents  the  infection  of  the  parotid  gland. 
We  have  had  no  parotiditis  in  any  case,  in  which  we  have 
directed  the  patient  to  chew  gum  directly  after  gastric 
operations,  while  formerly  this  condition  occurred  fre- 
quently enough  to  be  very  annoying. 

Occasionally  these  patients  suffer  from  acidity  of  the 
stomach  and  eructations  of  sour  substance.  Notwith- 
standing the  fact  that  previous  to  the  operation  there  may 
have  been  no  free  hydrochloric  acid  present.  In  these 
cases  it  is  well  to  give  from  15  to  30  drops  of  milk  of  mag- 
nesia or  10  to  20  grains  of  bicarbonate  of  soda  in  2  to  4 
ounces  of  water  in  sips  every  hour,  so  that  it  takes  the 
patient  about  half  an  hour  to  take  this  solution  and  half 
an  hour  to  rest  from  it. 

On  the  third  day  an  ounce  or  two  of  broth  or  water  gruel 
may  be  given  by  naouth  every  2  hours.  This  may  be  con- 
tinued for  3  or  4  days,  when  an  ounce  or  two  of  good 
buttermilk  with  an  ounce  or  two  of  cream  may  be  given 
once  or  twice  during  the  day.  The  white  of  an  egg  in  2 
to  4  ounces  of  water  may  then  be  given  and  later  a  sufficient 
amount  of  orange  juice  may  be  added  to  this  to  disguise  the 
egg.  In  each  instance  it  is  weU  to  give  the  bicarbonate  of 
soda  or  the  milk  of  magnesia  immediately  before  giving 
these  articles  of  food.  After  10  days,  milk  with  milk  of 
magnesia  may  be  given  regularly  and  the  patient  may  chew 
beef  or  mutton  and  swallow  the  juice  but  not  the  pulp. 


SUEGICAL  TEEATMENT  OF  CANCER  OF  THE  STOMACH      467 

It  is  wise  to  caution  these  patients  after  they  leave  the 
hospital  never  to  eat  any  raw  fruits  or  vegetables  (espe- 
cially not  those  that  are  likely  to  be  covered  with  manure) , 
like  lettuce,  radishes,  celery,  raw  onion,  etc.  It  is  also  well 
to  give  these  patients  a  definite  diet  list  which  they  may 
resort  to  any  time  when  their  new  digestive  apparatus 
refuses  to  digest  the  food  contained  in  the  regular  diet  list 
which  should  also  be  supphed  to  these  patients.  Thus 
it  is  absolutely  necessary  to  tyrannize  over  this  class  of 
patients  in  order  to  keep  them  in  good  condition  after 
these  operations,  because  as  a  rule  these  patients  are  pri- 
marily erratic  eaters  and  many  of  them  pride  themselves 
upon  being  able  to  eat  fooUsh  things  after  such  operations. 
We  have  had  a  number  of  patients  who  have  suffered 
severely  from  gastric  disturbances  as  the  result  of  some 
foohsh  act  of  this  kind.  While  many  others  have  been 
able  to  digest  their  food  normally  for  many  years  by 
adhering  to  a  reasonable  diet  similar  to  the  following: 

Diet  List  for  Use  when  Normal. — Drink  no  water 
and  no  other  Uquid  except  hot  milk  during  meals,  not  for  1 
hour  before  or  after  meals. 

Drink  an  abundance  of  good  water  between  meals. 

Drink  no  tea  or  coffee,  and  nothing  containing  alcohol. 

Eat  very  slowly  and  chew  all  your  food  for  a  long  time. 

Eat  nothing  very  sweet  or  very  sour. 

Eat  nothing  that  has  been  fried. 

Eat  no  hot  bread,  cake,  candy,  canned  goods,  pickles, 
pancakes,  puddings,  pie,  pastry  or  pork;  no  raw  vegetables 
or  raw  fruits,  unless  the  latter  are  perfectly  ripe  and  not  sour, 
no  bananas  or  raw  apples,  no  fried  onions  cabbage,  turnips, 
sweet  potatoes,  baked  beans,  corned  beef,  and  no  nuts. 

You  may  eat  broiled  or  stewed  beef  and  mutton,  breast 
of  chicken,  fish,  cooked  vegetables,  cooked  ripe  fruits,  bread, 


468  CANCER  OF  THE  STOMACH 

butter,  toast,  well  cooked  cereals,  rice,  milk  or  cream  soups 
and  vegetable  soups;  also  soft-boiled  or  poached  eggs. 

You  may  drink  milk,  cream  and  buttermilk. 

In  case  the  milk  of  magnesia  used  in  connection  with 
the  milk  in  the  following  diet  should  act  too  freeh'  upon 
the  bowels,  lime  water  may  be  substituted  for  it,  but  it  is 
best  to  add  one  or  the  other  to  the  milk  in  order  to  prevent 
such  from  coagulating  in  the  stomach  and  in  order  to 
alkahnize  the  milk. 

Patients  should  be  instructed  to  use  the  following  diet 
the  moment  they  feel  any  distress  and  not  to  wait  until  the 
digestive  apparatus  is  badly  out  of  order  before  giving  it 
the  rest  which  this  diet  affords. 

Diet  2. — Chew  all  food  for  a  long  time.  Eat  nothing 
sweet  or  sour. 

Take  }i  pint  of  hot  milk  with  1  or  2  teaspoonfuls  of 
milk  of  magnesia  or  2  to  4  tablespoonfuls  of  lime  water  at 
6,  8,  10,  12,  2,  4,  6  and  8.  Later  you  may  take  the  other 
articles  of  food  in  this  list  at  8,  12  and  6. 

First  Week. — Four  pints  of  hot  milk  daih'  with  milk  of 
magnesia  or  hme  water;  if  this  is  not  sufficient  to  keep 
your  strength  you  may  add  from  1  to  4  raw  eggs. 

Second  Week. — Same  as  first,  and  2  to  4  raw  or  soft-boiled 
eggs  in  addition. 

Third  Week. — Same  as  second,  and  2  to  6  pieces  of  very 
dry  toast  in  addition. 

Fourth  Week. — Same  as  third,  and  all  kinds  of  milk  or 
cream  soup  in  addition. 

Fifth  Week. — Same  as  fourth,  and  all  kinds  of  mush  or 
boiled  rice  in  addition. 

Sixth  Week. — Same  as  fifth,  and  broiled,  stewed  or  boiled 
beef  or  mutton  in  addition,  chew  and  swallow  the  juice, 
but  not  the  fiber. 


SURGICAL  TREATMENT  OF  CANCER  OF  THE  STOMACH      469 

Later  add  cooked  vegetables  and  cooked  fruits,  adding 
only  one  kind  each  week. 

Later  you  may  swallow  the  beef  or  the  mutton. 

Even  after  recovering  fully,  do  not  eat  pastry,  pie,  pan- 
cakes, pickles,  pork,  or  puddings.  No  cake,  candy  or 
canned  goods.  No  raw  vegetables  or  raw  fruits,  unless 
the  latter  are  perfectly  ripe  and  not  sour. 

EXCISION  OF  THE  COLON  IN  CASE  OF  CIRCUMSCRIBED  INVOLVE- 
MENT  OF  THE  TRANSVERSE   COLON   COMPLICATING 
CANCER   OF  THE  STOMACH 

Very  rarely  a  cancer  of  the  stomach  located  in  the  lowest 
portion  of  the  greater  curvature  may  become  adherent  to 
the  transverse  colon  during  the  early  period  of  its  develop- 
ment and  this  condition  may  lead  to  an  abdominal  section 
because  of  the  obstruction  of  the  passage  of  fecal  material 
through  the  transverse  colon  together  with  the  presence  of 
digestive  disturbance.  These  cases  are  extremely  rare  but 
they  occur  frequently  enough  to  warrant  a  description  of 
the  operation  which  will  be  required  in  this  case. 

The  operation  which  one  would  naturally  wish  to  perform 
would  consist  in  the  excision  of  the  transverse  colon  and 
the  union  by  means  of  the  suturing  of  the  two  ends.  This, 
however,  is  not  a  satisfactory  operation  because  the  pos- 
terior surface  of  the  transverse  colon  is  not  covered  with  the 
peritoneum  and  a  leakage  may  occur,  moreover  there  is 
likely  to  be  an  obstruction  to  the  passage  of  gas  and  feces 
at  this  point  of  union,  and  this  added  to  the  other  conditions 
is  likely  to  cause  trouble.  It  is  consequently  far  better 
to  remove  the  cecum,  the  ascending  colon  and  the  trans- 
verse colon  after  the  manner  practised  in  Lane's  operation; 
to  implant  the  end  of  the  ileum  into  the  sigmoid  flexure 
and  to  close  the  free  end  of  the  transverse  colon  at  the  point 
at  which  the  section  was  made. 


470  CANCER  OF  THE  STOMACH 

This  operation  at  once  removes  the  cancerous  portion 
of  the  transverse  colon  and  the  portion  of  the  omentum 
containing  the  infected  lymph  nodes  and  leaves  a  con- 
venient condition  for  performing  a  posterior  gastro-enteros- 
tomy.  The  excision  of  the  colon  should  be  made  before 
the  operation  upon  the  stomach  is  begun.  The  important 
points  in  this  operation  consist,  first,  in  securing  perfect 
hemostasis.  This  can  be  accomphshed  by  laying  bare  the 
peritoneum  covering  the  inner  side  of  the  cecum  and  grasp- 
ing the  blood-vessels  supplying  the  cecum,  and  the  hepatic 
flexure  of  the  colon  and  the  ascending  colon.  The  ileum 
is  then  clamped  between  two  powerful  forceps  from  5  to 
10  cm.  from  the  cecum  at  a  point  at  which  it  will  be  most 
convenient  to  implant  the  proximal  end  of  the  ileum  into 
the  sigmoid  flexure.  The  distal  end  is  then  removed 
together  with  the  cecum  and  the  ascending  colon. 

In  the  region  of  the  hepatic  flexure  of  the  colon  it  is 
important  to  guard  against  injuring  the  duodenum,  which 
often  projects  to  the  right  toward  the  right  kidney  pouch 
and  unless  this  fact  is  borne  in  mind  it  is  an  easy  matter  to 
injure  this  portion  of  the  duodenum.  When  the  hepatic 
flexure  of  the  colon  has  been  reached  it  is  best  to  abandon 
the  operation  for  a  time,  packing  the  space  made  bare 
with  gauze  pads  and  to  implant  the  proximal  end  of  the 
ileum  into  the  sigmoid  flexure,  care  being  taken  to  close 
the  space  behind  these  structures  to  prevent  a  future  hernia. 
Then  the  operation  is  again  resumed  in  the  region  of  the 
hepatic  flexure  of  the  colon,  the  duodenum  is  laid  bare,  the 
four  arteries  mentioned  in  gastrectomy  are  clamped  and 
the  pyloric  end  of  the  stomach  is  removed  together  with 
the  transverse  colon,  care  being  taken  to  grasp  the  middle 
colic  artery  with  two  pairs  of  forceps  and  to  cut  it  before 
traction  is  made  upon  it. 


SUEGICAL  TREATMENT  OF  CAXCER  OF  THE  STOMACH      471 

The  colon  is  then  clamped  between  two  strong  clamps  at 
least  7  cm.  beyond  the  tumor  and  the  entire  structure  up 
to  that  point  together  with  the  pyloric  end  of  the  stomach 
and  the  omentum  are  removed  together  with  all  of  the 
lymph  nodes  contained  in  this  region.  The  duodenum  and 
the  stomach  are  then  treated  as  in  the  operations  described 
above.  The  gastro-jejunostomy  is  also  performed  after 
the  method  already  described  and  the  entire  raw  surface 
which  has  been  produced  by  the  removal  of  the  portion  of 
the  ileum,  the  cecum,  the  ascending  colon,  the  transverse 
colon  and  the  pyloric  end  of  the  stomach  are  carefully 
covered  with  peritoneum  and  the  remnant  of  omentum  is 
sutured  over  this  surface.  The  operation  is  completed 
after  the  method  described  in  gastrectom3\ 

By  carrying  out  this  operation  systematically  according 
to  the  method  just  described,  being  careful  throughout  the 
operation  to  keep  the  small  intestine  packed  away  from 
the  field  of  operation  and  by  avoiding  all  unnecessary 
manipulation  of  the  intraabdominal  organs,  it  is  possible  to 
complete  this  operation  in  a  relatively  short  length  of  time 
and  to  reduce  the  shock  to  a  minimum.  Xormal  salt 
solution  and  concentrated  predigested  food  may  be  given 
by  rectum  immediately  after  the  operation  and  it  is  wise 
to  give  from  1,000  to  1,500  cc.  of  normal  salt  solution 
under  the  breasts  directh'  after  the  operation  and  to  repeat 
this  twice  a  day  for  2  or  3  days  until  the  patient  can  take 
fluid  by  mouth. 

The  after-treatment  is  the  same  as  that  which  has  already 
been  described. 


CHAPTER  XII 
NON-SURGICAL  TREATMENT 

Prophylaxis. — All  patients  with  obstinate  dyspepsia 
should  be  advised  to  submit  to  laparotomy  at  the  hands  of 
a  competent  surgeon.  While  experience  has  shown  that 
there  is  no  '^  cancer  age,"  it  is  a  proven  fact  that  individuals 
above  the  age  of  35  years  are  more  prone  to  malignant  dis- 
ease than  are  those  below  such  age.  Abdominal  explora- 
tion is  a  safe  procedure  with  modern  operative  aids.  Its 
teachings  are  of  such  worth  that  in  suspected  gastric  cancer 
or  atypical  dyspepsia,  the  procedure  should  be  resorted  to 
more  frequently  than  it  now  is.  It  is  a  curious  condition  of 
the  professional  mind  which  permits  argument  against  lap- 
arotomy, where  even  expert  non-surgical  treatment  has 
failed.  Patients  in  America  are  rarely  greatly  alarmed 
when  competent  authorities  recommend  laparotomy  as  a 
solution  of  their  disturbances  of  digestion.  On  the  con- 
trary, many  individuals  are  so  weary  of  ineffectual  attempts 
to  aid  them  by  types  of  therapy  ranging  from  crystal-gazing 
to  almost  permanent  residence  in  hospitals  or  sanatoria, 
that  they  eagerly  look  forward  to  surgical  intervention  as  a 
way  out  of  their  dyspeptic  dilemmas. 

Individuals  in  middle  life,  who  have  unaccountably 
developed  faulty  digestion,  should  be  carefully  examined 
for  anomalies  of  the  circulatory  system,  the  kidneys,  the 
blood  and  the  blood-forming  organs  or  the  central  nervous 
system.  If  disease  is  not  located  in  such  organs,  and 
infective  processes  can  be  excluded,  the  patient  should  be 

472 


NON-SURGICAL   TREATMENT  473 

told  the  possibilities  of  a  malignant  termination  of  his 
ailment  and  advised  to  consult  a  reputable  surgeon. 

Chronic,  recurrent,  or  frequently  bleeding  ulcers,  should 
be  treated  as  potential  or  actual  cancers  and  removed  when 
possible. 

In  all  types  of  cases,  diagnosis  should  not  be  withheld  until 
everybody  recognizes  cancer  but  the  guileless  patient  or 
his  optimistic  physician,  '\^^len  the  patient  can  answer 
''yes"  to  all  the  signs  and  symptoms  of  gastric  cancer  set 
down  in  the  text-books,  he  would  do  well  to  get  his  affairs 
in  order,  for  no  form  of  treatment  is  then  of  permanent 
avail.  While  scientifically  conducted  chnical  investiga- 
tions of  gastric  ailments  have  returned  facts  of  much  diag- 
nostic worth,  the  doctrine  that  the  physicians  must  wait 
until  analysis  of  the  gastric  extracts  from  dyspeptics  shows 
absent  free  hydrochloric  acid  before  they  call  a  disease 
cancer,  has  sent  more  people  to  the  grave  than  have  ab- 
dominal explorations,  however  poorly  such  may  have  been 
performed.  When  made  by  trained  surgeons,  abdominal 
section  is  attended  by  a  mortality  of  about  3^^  of  1  per  cent. 
There  is  a  mortality  of  100  per  cent,  in  the  non-surgical 
treatment  of  gastric  cancer. 

The  first  aim  of  prophylaxis  then,  should  be  the  eradica- 
tion from  the  human  family  of  all  potential  or  actual  malig- 
nancy by  surgical  means.  So  long  as  we  are  in  ignorance 
regarding  the  etiology  of  all  cancer,  and  inasmuch  as  the 
question  of  its  parasitic  or  its  constitutional  origin  is  a 
debatable  one,  it  behooves  medical  men  everywhere  to 
urge  early  radical  treatment  of  the  disease. 

In  view  of  the  fact  that  it  has  been  shown  that  cancer  is 
not  infrequently  more  prevalent  in  certain  districts,  houses 
or  famihes,  it  would  seem  proper  to  systematically  study 
such  localities,  dwellings  or  families  with  a  hope  of  ascer- 


474  CANCER  OF  THE  STOMACH 

taining  etiologic  information  or  to  segregate  affected  in- 
dividuals as  a  preventive  measure.  Intermarriage  of 
cancerous  folk,  especially  members  of  cancer  families, 
should  be  interdicted.  While  no  one  can  say  positively  that 
hereditary  transmission  of  cancer  takes  place,  it  is  not  pos- 
sible to  state  that  certain  tendencies  toward  malignancy 
are  not  transmitted  from  one  generation  to  another. 

Registration  of  cancer  cases  should  be  required  of  physi- 
cians by  both  local,  state  and  federal  authorities.  Such 
reports  should  fully  cover  the  etiologic,  clinical  and  patho- 
logic features  connected  with  such  patients. 

General  Measures. — There  are  really  three  main  groups 
of  patients  for  which  medical  treatment  is  indicated.  These 
comprise  patients  in  whom  external  evidences  of  metastases 
(to  lymph  glands,  liver,  peritoneum)  contraindicate  sur- 
gery; those  on  whom  operations  have  been  performed  and 
instances  where  surgical  measures  are  indicated,  but 
complications  (hemorrhage,  vomiting,  exhaustion)  prevent 
immediate  operation. 

It  is  not  necessary  that  patients  know  how  seriously 
they  are  affected.  Some  individuals  demand  a  statement 
of  their  exact  condition.  One  should  use  tact  in  imparting 
such  knowledge.  To  a  member  of  the  family,  a  blood- 
relative,  or  a  trusted  friend,  the  ailment  and  its  conse- 
quences should  be  fully  described.  While  no  hope  of  non- 
surgical cure  of  cases  of  gastric  cancer  exists,  much  may 
be  done  to  make  these  unfortunates  comfortable. 

Care  of  the  Teeth  and  Oral  Cavity. — As  we  have  pre- 
viously pointed  out,  many  patients  with  malignant  disease 
of  the  stomach  have  imperfect  or  dirty  teeth.  While  no 
one  has  absolutely  demonstrated  the  deleterious  effects 
upon  injured  gastric  mucosse  of  swallowed,  atypic  mouth 
enzymes,  amino-acids  {e.g.,  tryptophan),  pus,  bits  of  teeth, 


NON-SURGICAL   TREATMENT  475 

bacteria  or  protozoa,  it  would  appear  safe  to  admit  that 
such  substances  throw  an  excessive  amount  of  unnecessary 
labor  upon  the  body's  defensive  mechanism.  Decayed 
teeth  should  be  extracted  and  imperfect  teeth  repaired. 
Cancer  patients  usually  endure  extraction  of  teeth  well. 
If  properly  carried  out  this  operation  requires  no  more 
anesthetic  than  a  few  whiffs  of  ether.  In  many  instances, 
the  work  can  be  done  under  local  anesthesia.  Follow- 
ing the  extraction  of  the  teeth,  hemorrhage  is  generally 
controlled  by  having  the  patient  bite  upon  a  firm 
gauze  roll.  If  this  does  not  suffice,  bits  of  ice  may  be 
allowed  to  dissolve  in  the  mouth,  or  the  gums  may  be 
sprayed  with  weak  adrenalin  solution.  Hypodermatic  ad- 
ministration of  morphine  sulphate  (gr.  }i)  often  aids  in  con- 
trolling bleeding,  and  is  a  useful  medicine  to  exhibit  where 
pain  is  annoying  or  the  patient  is  nervous.  If  seepage  of 
blood  from  the  torn  gums  continues  for  longer  than  24 
hours,  active  horse  serum  should  be  administered  (10  cc. 
doses,  2  or  3  times  during  the  day  usually  suffice)  intra- 
muscularly or  intravenously.  Where  hemorrhage  is  pro- 
longed, and  symptoms  of  shock  appear,  transfusion  of 
human  blood  from  a  relative  is  indicated.  In  our  expe- 
rience, this  maneuver  is  most  satisfactorily  performed  by 
the  PercyrCook  method  (see  below). 

To  contract  the  gums  after  the  extraction  of  teeth,  a 
useful  mouth-wash  is  Dobell's  fluid  to  which  has  been 
added  formalin  to  make  a  1  per  cent,  solution.  This  wash 
has  also  hemostatic  and  bactericidal  properties.  It 
can  be  used  after  each  feeding.  One  need  scarcely  men- 
tion that  liquid  or  very  soft  food  should  be  given  until 
the  gums  have  healed.  Proper  fitting  artificial  teeth  should 
be  inserted  as  soon  as  the  gums  are  healed  and  firm. 

Oral  cleanliness  should  be  sought  apart  from  removal  of 


476  CANCER  OF  THE  STOMACH 

decaying  teeth.  Oozing,  soggy,  pus-laiden  gums  should 
be  freely  incised.  Small  abscess  cavities  may  be  lightly 
swabbed  with  2  per  cent,  solution  of  silver  nitrate,  10  per 
cent,  formalin  solution  or  dilute  tincture  of  iodine.  Foul 
tonsils  or  other  infected  adenoid  tissue  should  be  extirpated, 
if  possible.  If  this  cannot  be  done,  then  cauterization  of 
disease  foci  should  be  thoroughly  performed. 

It  is  often  astonishing  to  note  the  feeling  of  well-being 
which  gastric  cancer  patients  exhibit  after  their  mouths 
have  been  cleaned  up.  Appetite  may  return,  food  may  be 
eaten  in  abundance,  gain  in  weight  occur,  and  such  general 
improvement  supervene  as  to  arouse  hopes  of  a  mistake 
in  diagnosis  or  of  spontaneous  regression  of  the  neoplasm. 

The  toilet  of  the  stomach  should  be  as  carefully  taken 
care  of  as  in  the  case  of  the  oral  cavity.  This  demands 
attention  in  all  instances  of  gastric  cancer,  whether  they  be 
of  the  retention  or  the  non-retention  type. 

The  reduction  to  a  minimum  of  the  swallowing  of  foul 
substances  from  the  mouth  is  an  important  step  toward 
gastric  cleanliness.  Even  with  this  source  of  infection 
limited,  the  stomach  is  yet  burdened,  as  a  rule,  with  ob- 
noxious material  in  the  form  of  retained  food,  altered  blood, 
products  of  tissue  necrosis,  bacteria  and  foreign  chemical 
compounds.  Much  can  be  done  by  regulating  the  kind 
of  diet  (see  below).  Other  measures  are  2  ounces  of 
oleum  ricini  (in  beer,  malt  extract,  acid  fruit  juices  or 
administered  through  a  stomach  tube)  at  least  once  weekly; 
lavage  of  the  stomach  with  solutions  of  2  per  cent,  formalin, 
1  per  cent,  salicylic  acid,  0.5  per  cent,  thymol,  1-2,000 
quinine,  or  1-3,000  alphozone  (follow  the  medicinal  lavage 
by  a  washing  with  normal  salt  solution  at  37°  C.) ;  the  ex- 
hibition of  gtt.  xxx  dilute  hydrochloric  acid  (U.S. P.) 
y^  hour  after  eating,  or  the  administration  of  oil  of  eucalyp- 


NON-SURGICAL    TREATMENT  477 

tus  (gtt.  XV — t.i.d.  a.c),  radium  water  (oj  to  gss  on 
an  empty  stomach  several  times  daily),  or  bismuth  sub- 
carbonate  (gr.  XXX,  when  Uquid  food  is  taken  or  upon  the 
empty  stomach,  4  times  daily). 

Of  all  the  above  means  of  keeping  the  stomach  clean,  diet 
and  frequent  lavage  are,  undoubtedly,  the  most  satisfactory. 
Patients  readily  become  accustomed  to  the  daily  use  of 
the  stomach  tube,  and  chng  to  it  when  they  discover  how 
great  is  their  rehef  from  annoying  sj'-mptoms  by  lavage. 
The  best  time  to  wash  out  the  stomach  is  when  the  patient 
experiences  the  greatest  discomfort.  Usually  a  generous 
lavage  before  the  morning  meal,  or  the  last  thing  at  night, 
will  insure  the  greatest  measure  of  cleanliness  and  comfort. 
Patients  with  far  advanced  gastric  cancer  may  require 
lavage  several  times  daily. 

Diet. — Feeding  is  always  a  serious  problem  in  this  disease. 
What  agrees  with  one  patient  is  often  unbearable  to 
another.  Routine  diet  tables  will  be  found  to  have  but  a 
general  appUcation.  The  type  of  food  will  frequently 
require  changing  in  a  given  patient.  It  thus  follows  that 
dieting  in  gastric  cancer  is  a  highly  individual  problem. 

Not  infrequently,  success  in  feeding  these  unfortunates 
rests  upon  the  correct  estimation  of  the  position  occupied 
by  the  stomach  tumor.  Growths  at  or  near  the  cardia 
sometimes  call  for  administration  of  very  soft  or  liquid  food. 
This  may  have  to  be  given  through  a  long  catheter,  or  a 
stomach  tube  of  small  cahber  passed  beyond  the  constric- 
tion. It  may  be  necessary  to  constantly  use  this  method 
of  feeding,  but  not  rarely  growths  near  the  entrance  to  the 
stomach  slough  extensively,  and  so  permit  periods  of  rehef 
from  tube  life.  Extensive,  canalized  growths  in  the  body 
of  the  stomach  often  allow  the  exhibition  of  weU-chewed, 
mixed  food  for  a  long  time.     The  patient's  desires  should 


478  CANCER  OF  THE  STOMACH 

be  humored  in  such  event.  WTien  early  or  late  pyloric 
steiiosis  has  occurred,  it  may  be  impossible  to  get  a  proper 
quantity  of  nom'ishment  beyond  the  stomach.  In  mild 
stenoses  where  the  normal  way  of  food  ingestion  causes 
distress  or  pain,  or  where  gastric  atony  and  dilatation  result 
in  the  constant  presence  of  foul  stagnation  products  in  the 
stomach,  considerable  relief  from  discomfort  and  sufficient 
nutriment  may  be  obtained  by  metagastric  (duodeno- 
jejunal) or  so-called  ''duodenal"  alimentation. 

Metagastric  alimentation  is  of  service  where  it  is  possible 
for  the  bulb  of  the  ''duodenal  tube"  or  the  end  of  a  post- 
gastric  catheter  to  pass  beyond  the  pylorus.  It  has  been 
our  observation  (corroborated  by  fluoroscopic  examina- 
tions) that  in  many  instances  duodenal  tubes  do  not  pass 
through  the  pylorus.  Unfortunately  in  the  very  class  of 
case  in  which  this  mode  of  feeding  is  most  desirable,  there 
is  mechanical  hindrance  to  its  successful  apphcation. 
Not  only  in  pyloric  cancer  does  the  bulb  fail  to  pass  into 
the  duodenum,  but  we  have  learned  that  not  infrequently 
the  end  of  the  tube  gets  caught  between  nodular  projec- 
tions of  the  growth  and  material  forced  through  it  lodges 
in  the  stomach.  Where  the  gastric  lumen  is  tortuous, 
this  occurrence  is  quite  common.  Ordinary  duodenal 
tubes  m.ust  remain  in  situ  for  long  periods  of  time.  This 
renders  the  method  an  inconvenient,  as  well  as  one  not 
altogether  desirable,  from  the  standpoint  of  cleanhness. 

The  form  of  postgastric  catheter  that  can  be  passed 
directly  into  the  small  bowel  upon  a  silk-cord  guide  is,  in 
our  experience,  the  most  satisfactory.  One  can  be  reason- 
ably sure  that  food  is  reaching  the  desired  locality,  the 
amount  given  can  be  computed,  the  patient  is  less  incon- 
venienced by  a  thread  being  constantly  present  in  his  throat 
and  mouth  than  by  a  rubber  tube,  and,  lastly,  it  is  possible 


NON-SUEGICAL   TREATMENT  479 

to  keep  tubes  clean  that  need  only  be  present  in  the 
alimentarj"  tract  at  the  time  food  is  given. 

Various  nourishing  mixtures  may  be  administered  by 
the  metagastric  method.  Those  commonly  found  useful 
are  parboiled  milk,  cream,  buttermilk,  malted  milk,  koumiss, 
wines,  cocoa,  chocolate,  thin  purees,  clear  broth,  egg-nogg, 
barley-water,  black  coffee,  tea,  carbonated  preparations, 
predigested  foods,  fruit  juices,  sugar  water,  or  special 
formulae.  There  is  a  wide  range.  From  2  to  8  ounces 
should  be  administered  at  a  time.  The  material  should 
be  at  37°  C.  and  be  passed  in  slowly.  If  one  can  be  sure 
that  the  distal  end  of  the  feeding-tube  is  alwaj^s  patent, 
then  nutrient  mixtures  may  be  given  by  a  modified  "drop- 
method." 

In  instances  where  emaciation  has  been  marked,  we 
have  found  it  useful  to  feed  patients  by  the  metagastric 
method,  mixtures  of  amino-acids  and  maltose.  Such  are 
readily  prepared  by  first  digesting  Witte-peptone  in  normal 
salt  by  trypsin  (Fairchild)  under  toluol  or  in  0.4  per  cent, 
alphozone-normal  salt  solution,  and  then  adding  sufficient 
maltose  to  make  a  5  per  cent,  mixture.  From  100  to 
.500  cc.  may  be  administered  through  the  post-gastric 
catheter  every  3  hours.  If  thirst  is  excessive,  similar  quan- 
tities of  normal  salt  solution  at  37°  C.  should  be  given 
10  -minutes  before  the  amino-acid  maltose  preparation. 

Where  the  gastric  lumen  is  patent  the  essential  feature  of 
successful  dieting  is  to  allow  only  such  food  as  will  cause 
Httle  irritation  and  will  pass  through  the  stomach  leaving 
the  minimum  of  residue.  Lumps  of  food  are  hkely  to  in- 
jure the  diseased  gastric  lining,  produce  or  keep  up  a  hemor- 
rhage and,  by  stagnating  in  the  stomach,  furnish  a  constant 
source  of  irritation  as  well  as  an  ideal  culture  media  for  a 
host   of   inimical   bacteria.     Care   should   be   taken   that 


480  CANCER    OF    THE    STOMACH 

foods  are  not  too  hot  or  too  cold.  Hot  foods  cause  gastric 
congestion  or  even  hemorrhage  in  cancer,  while  cold  foods 
may  be  responsible  for  painful  gastro-spasms. 

Uncooked  vegetables  and  fruits  should  be  interdicted, 
not  only  on  account  of  the  possibility  of  their  being 
mechanical  irritants,  but  also  because  they  are  a  common 
source  of  infection.  It  has  been  frequently  pointed  out 
by  Ochsner,  that  fann  produce  is  generally  contaminated 
by  manm'e-impregnated  soil.  It  is  not  essential  to  beUeve 
that  these  uncooked  foods  caxry  a  parasite  capable  of  caus- 
ing cancer,  in  order  to  hmit  their  use.  Anyone  who  has 
taken  the  trouble  to  examine  microscopically  or  chemically, 
the  dung  which  is  ordinarily  used  to  force,  ripen  or  bleach 
garden  products,  will  admit  that  the  possibihties  of  such, 
when  taken  raw,  acting  as  sources  of  infection,  cannot 
be  denied.  It  is  a  rather  striking  fact  that  in  communities 
where  an  excess  of  uncooked  vegetables  or  ''greens" 
comprises  a  good  share  of  the  diet,  gastric  cancer  is  very 
prevalent.  Among  city  dwellers,  of  the  well-to-do  class, 
who  can  afford  fresh  garden  products,  the  cancer  rate  is 
hkewise  high.  The  interesting  and  valuable  investigations 
of  Smith  relative  to  the  production  of  tumors  in  daisies 
from  bacilh  isolated  from  ''galls"  would  appear  to  indicate 
that  raw  ''greens"  or  vegetables  might  be  a  source  of  gastric 
irritation.  The  researches  of  Gaylord,  upon  the  develop- 
ment of  tumors  in  fish  that  Hve  in  water  highly  contami- 
nated by  their  own  discharges,  are  not  without  significance 
in  pointing  out  the  dangers  attending  ingestion  of 
bacteriallj'-  or  chemically  filthy  food. 

With  the  increase  in  the  population  of  the  globe  there 
has  been  an  increase  in  cancer  generally — particularly  in 
gastric  cancer.  What  effect,  through  pollution  of  water 
supphes  and  food,  this  increase  has  exerted  toward  causing 


NON-SURGICAL   TREATMENT  481 

the  disease,  we  can  but  conjecture.  The  end-result  is 
worthy  of  thought. 

Rectal  Feeding. — This  may  be  required  after  hemorrhage, 
on  account  of  pain,  in  ''coma  carcinomatosa "  where 
exhaustion  has  resulted  from  loss  of  appetite,  nausea, 
vomiting,  in  starvation  due  to  stenoses,  or  to  allay  thirst. 

Rectal  aUmentation  is  best  administered  by  the  ''Murphy 
drip"  method.  The  patient  should  lie  with  hips 
elevated  upon  one  or  two  pillows.  Cleansing  the  colon 
with  normal  salt  solution  should  be  performed  before  the 
nutrient  enema  is  given.  The  clystra  should  be  given  at  a 
temperature  of  37°  C.  In  ordinary  cases  enemata  are  well 
retained.  If  they  are  expelled  promptly,  more  care  should 
be  taken  in  their  administration,  or  gtt.  v-xx  of  tincture 
opii  and  gtt.  iii  to  x  of  tincture  belladonna,  may  be  in- 
corporated in  every  second  enema.  From  4  to  8  ounces  of 
nutrient  fluid  nday  be  given  at  intervals  of  from  4  to  6 
hours.  If  these  feedings  are  combined  with  nourishment 
per  Oram,  it  is  well  to  give  but  two  daily. 

Various  formulae  for  nutrient  enemata  are  in  vogue.  We 
have  found  the  following  useful: 

Maltose  or    30 . 0  grams 

Alcohol  (95  per  cent.)  or    20.0     cc. 

Peptonized  milk  or  100.0     cc. 

Normal  salt  solution  q.  s.  ad  viii  or  240 . 0     cc. 
Mix.— Heat  to  37°  C. 
Sig. — Administer  slowly. 

Other  enemata  of  value  are  parboiled  milk  ( 5  v  every  3 
hours) ;  glucose  (§ij  to  §  viii  normal  salt  solution),  egg  albu- 
men and  maltose  (whites  of  2  eggs,  maltose  §  j  in  normal 
salt  solution  to  §  viii) .  It  is  doubtful  if  anything  of  more 
use  than  water,  salts  or  alcohol  is  absorbed  from  certain  of 

31 


482  ,€ANCEK  OF  THE  STOMACH 

^'nutrient"  mixtures  comprising  eggs,  starch,  proprietary 
predigested  foods,  beef  extracts  and  the  Hke. 

To  two  patients  we  have  given  enemata  composed  of 
amino-acids  and  maltose  with  seeming  benefit,  but  the 
procedure  is  still  on  trial. 

MANAGEMENT  OF  SYMPTOMS 

Anorexia  is  not  infrequently  a  most  annoying  symptom 
in  gastric  cancer.  The  desire  for  certain  kinds  of  food  is 
lost.  This  may  amount  to  an  actual  aversion.  Some 
patients  early  lose  their  appetites  for  meat  products, 
milk  or  sweets.  The  change  of  food  desire  for  the  in- 
dividual is  not  infrequently  radical.  The  appetite  is 
best  stimulated  by  lavage,  catharsis,  the  employment 
of  hot  baths,  massage,  attempt  at  change  of  mental  at- 
titude, or  by  a  vacation. 

Early  lavage  often  prevents  anorexia.  Its  effect  is 
both  tonic  and  cleansing.  After  the  stomach  has  once 
been  relieved  of  such  accumulation  as  may  exist  at  the 
time  the  patient  comes  under  observation,  it  is  not  nec- 
essary to  use  medicinal  remedies  in  the  wash  water. 
Normal  salt  solution  at  37°  C.  acts  very  well  in  most 
instances,  and  is  readily  prepared.  In  cases  where  the 
gastric  retention  is  very  marked,  or  where  a  widely  slough- 
ing growth  constantly  befouls  the  stomach,  lavage  with 
Carlsbad  water  (1  dram  of  Carlsbad  Salts  to  1,000  cc. 
of  water  at  37°  C),  1  per  cent.  salicyUc  acid  solution  or 
0.5  per  cent,  solution  of  lysol  are  usually  of  service. 

Vom.iting. — In  many  instances  vomiting  is  due  to  im- 
proper food,  overfeeding,  obstruction  or  pain. 

If  the  diet  is  altered  so  that  it  is  enticing,  and  care  is 
taken  that,  with  the  eager  attempt  to  regain  health,  the 
patient   does   not   overload   his   stomach,    much    of    the 


NON-SURGICAL   TREATMENT  483 

vomiting  may  cease.  When  pain  is  the  cause  of  the  emesis 
(see  below)  simple  remedies  to  reheve  such  should  be 
promptly  instituted. 

In  cases  where  stenoses  produce  early  with  a  constant 
amount  of  gastric  stagnation,  lavage  usually  takes  care  of 
the  annoying  vomiting.  It  may  be  performed  fearlessly 
provided  a  soft  stomach  tube  is  used.  Only  in  instances 
where  there  has  been  severe  hemorrhage,  is  it  contra- 
indicated.  We  have  frequently  observed,  however,  that 
hemorrhage  itself  may  initiate  a  prolonged  attack  of 
vomiting  which  may  not  cease  until  the  blood  clots  have 
been  washed  from  the  stomach.  We  have  often  thor- 
oughly lavaged  a  stomach  within  a  few  minutes  after  a 
severe  hemorrhage  without  untoward  symptoms  on  the 
part  of  the  patient. 

Medicinal  remedies  are  of  but  secondary  value  in  the 
treatment  of  vomiting  unless  they  attack  one  of  its  under- 
lying causes. 

We  have  found  that  severe  retching,  with  or  without 
vomiting,  can  be  controlled  by  orthoform  (grains  10  every 
4  hours;  taken  on  an  empty  stomach),  chloroform  (gtt. 
10-30)  administered  after  lavage,  or  potassium  bromide 
(grains  30-60)  per  rectum.  Occasionally  there  are  cases 
where  vomiting  is  so  annoying  that  it  is  necessary  to 
administer  opiates.  These  should  be  given  by  the  physician 
himself  and  preferably  hypodermatically. 

Acidity,  Pyrosis  and  Eructation. — Such  are  not  rarely 
extremely  annoying.  Regulation  of  the  diet  combined 
with  catharsis  and  frequent  gastric  lavage  do  much  to 
prevent  or  relieve  these  symptoms. 

The  administration  of  hydrochloric  acid  (gtt.  15-30 
after  meals)  aids  in  limiting  intragastric  fermentation,  and 
in  this  way  acts  to  relieve  pyrosis  and  eructations,  which 


484  CANCER  OF  THE  STOMACH 

are  largely  due  in  this  disease  to  fermentation  and  organic 
acids.  If  gastric  lavage  is  not  used  to  remove  stagnant 
contents  from  the  stomach,  or  if  fermentation  of  such 
contents  is  not  prevented,  then  it  may  be  occasionally 
necessary  to  employ  alkalies  to  neutralize  the  high  com- 
bined acidity.  This  is  a  slovenly  way  to  aid  the  patient, 
although  at  times  it  may  prove  of  value  in  reUeving  symp- 
toms. We  have  found  that  alkalies  given  in  the  form  of 
bismuth  subcarbonate  (grains  30)  and  calcined  magnesia 
(grains  20)  prove  useful  in  such  emergencies. 

Bowels. — If  constipation  exists — and  it  frequently  does — 
2  ounces  of  castor  oil  in  beer  or  fruit  juices  may  be  given 
once  or  even  twice  weekly.  There  is  nothing  superior  to 
castor  oil  for  emptying  the  intestinal  tract  of  contaminating 
and  putrefying  contents.  Where  castor  oil  is  not  well 
borne,  from  J^  to  2  ounces  of  liquid  paraffin  may  be  ad- 
ministered, preferably  on  an  empty  stomach.  There  are 
instances  where  from  3  to  5  grains  of  calomel  given  at  bed 
time  are  useful  in  relieving  the  bowels,  and  at  the  same  time 
overcoming  flatulence.  Mild  cathartics  which  retain  their 
activity  for  a  long  time  are  phenolphthalein  (grains  5- 
10),  cascara  sagrada  (gtt.  15-60  at  bedtime)  or  compound 
jalap  powder  (grains  30-60  at  bed  time). 

Where  the  stools  show  an  excess  of  mucus,  hot  Carlsbad 
water,  or  solutions  of  sodium  phosphate  or  sodium  citrate, 
should  be  given  before  the  first  feeding  in  the  morning. 

Not  infrequently,  diarrhoea  is  an  annoying  symptom. 
There  are  cases  where  no  medicinal  agent,  other  than  opi- 
ates, will  be  found  of  service.  Everything  else  should  be 
tried,  however,  before  morphine,  codein  or  the  like  are  used. 

Keeping  the  stomach  clean,  putting  the  patient  for  a 
few  days  upon  a  diet  of  parboiled  milk  or  buttermilk, 
rest  in  bed,  or  hot  applications  over  the  abdomen,  some- 


NON-SUEGICAL    TREATMENT  485 

times  stop  exhausting  diarrhcea.  TVTiere  simple  measures 
fail,  bismuth  subgallate  (grains  10)  may  be  given  after  each 
bowel  movement.  Tannigen,  tannic  acid,  or  a  pill  com- 
posed of  opium  and  camphor  may  also  be  of  service. 

When  opiates  are  indicated  they  may  be  administered 
in  the  form  of  laudanum  (gtt.  10-40)  or  paregoric,  by  mouth 
or  in  starch-water  enemata.  Codein  or  morphine  should 
not  be  used  unless  absolutely  necessary  inasmuch  as  not 
infrequently  they  produce  nausea,  rapid  emaciation,  to- 
gether with  physical  and  psychic  unrest. 

Pain.— In  but  15  per  cent,  of  instances  of  gastric  cancer 
is  the  pain  sharp,  cohcky  or  prostrating.  These  are  cases 
where  ulceration  exists  or  perforation  has  taken  place. 
In  these  emergencies,  opiates  should  be  administered 
promptly  and  preferably  by  the  hypodermic  needle.  Pa- 
tients should  be  kept  in  bed,  and  after  preUminary  lavage, 
hot  apphcations  should  be  applied  to  the  epigastrium.  If 
hemorrhage  complicates,  an  ice-bag  or  ice-coil  locally  should 
be  used. 

Much  of  the  abdominal  distress  in  gastric  cancer  is  due 
to  accumulation  in  the  stomach  of  gas  or  stagnant  material. 
In  such  instances  the  stomach  tube  should  be  hberally 
employed.  There  are  instances  where  improper  diet  causes 
epigastric  pain.  This  error  should  be  corrected.  At  times 
it  will  be  found  necessary  to  administer  such  remedies  as 
chloroform  water,  orthoform,  bismuth,  creosote,  or  even 
opiates. 

Flatulence. — A  cold  enema  given  in  the  morning  will  be 
found  of  considerable  value  in  preventing  or  treating  this 
sometimes  annoying  sjmiptom.  Where  a  patient  is  bed- 
ridden, and  there  is  a  constant  tendency  to  gaseous  dis- 
tention of  the  bowel,  a  rectal  tube  of  fair  caliber  may  be 
inserted  5  times  a  dav  and  left  in  situ  for  from  10  minutes 


486  CANCER  OF  THE  STOMACH 

to  a  li  hour.  Where  pronounced  gastro-intestinal  fermen- 
tation exists,  alleviation  may  be  secured  by  the  administra- 
tion of  from  one  to  six  tubes  of  liquid  culture  of  Bacillus 
bulgaricus  (Metchnikoff)  daily. 

Hemorrhage. — It  is  impossible  to  prevent  the  more  or 
less  constant  seepage  of  blood  that  occurs  in  certain  types 
of  gastric  maUgnancy.  The  hemorrhage  which  it  is  neces- 
sary to  treat  is  that  which  occurs  acutely,  or  where  constant 
seepage  has  produced  marked  anemia  which  prevents  sur- 
gical intervention  in  an  otherwise  operable  case.  The  acute 
hemorrhage  of  gastric  cancer  is  best  treated  by  prompt 
lavage  of  the  stomach  with  normal  salt  solution  (37°  C), 
hypodermic  administration  of  morphine  (grains  M-3^), 
absolute  rest  in  bed,  ice-coil  to  the  abdomen,  heat  externally 
and  the  institution  of  rectal  feeding.  If  hemorrhage  does 
not  cease  within  a  few  hours,  horse  serum  in  from  10  to  100 
cc.  doses  should  be  given  hypodermatically.  This  can  be  re- 
peated several  times  in  the  course  of  24  to  48  hours.  The 
preparation  known  as  ''coagulose"  devised  from  the  experi- 
mental work  of  Clowes  of  the  Buffalo  Cancer  Research 
Laboratory  may  be  found  of  service  where  horse  serum  has 
proven  to  be  ineffective.  We  have  observed  that  several 
instances  of  persistent  hemorrhage  were  satisfactorily 
treated  by  the  direct  transfusion  of  human  blood  after  the 
method  of  Percy  and  Cook.  The  latter  describes  the 
technique  as  follows: 

A  Simple  Method  of  Blood  Transfusion. — A  method  of 
blood  transfusion  which  presents  many  desirable  features 
has  been  in  use  at  Augustana  Hospital  long  enough  to 
establish  its  value  as  a  means  of  relieving  anemia  and  in- 
creasing resistance. 

The  blood  is  aspirated  into  a  specially  prepared  trans- 
fusion tube  from  a  good  sized  vein  of  the  donor  and  injected, 


NON-SURGICAL    TREATMENT  487 

before  it  has  opportunity  to  coagulate,  into  a  similar  vein  of 
the  patient. 

The  Transfusion  Tube. — ^The  transfusion  tube  is  made 
from  soft  carefully  annealed  German  glass.  It  consists  of 
a  graduated  cylinder  about  16  inches  long  and  of  about 
650  cc.  capacity.  The  lower  end  of  this  cylinder  is  drawn 
out  at  right  angles  to  its  axis  to  form  the  canula  which  is 
inserted  directly  into  the  vein.  The  upper  end  or  mouth 
of  the  cylinder  is  drawn  out  at  right  angles  to  its  axis  but 
is  perpendicular  to  the  canula.  This  end  is  made  about 
4  inches  long  and  about  %  inch  in  diameter.  Over  it  is 
slipped  a  rubber  tube  about  15  inches  long  which  ends  in  a 
small  glass  tip  or  mouth  piece.  A  glass  tee  or  branch  is 
inserted  at  about  6  inches  from  the  cylinder,  cutting  the 
rubber  tube  in  2  parts,  6  and  9  inches  long.  To  the  side 
branch  of  the  glass  tee  an  ordinary  rubber  atomizer  bulb 
is  connected  by  a  piece  of  rubber  tubing  2  inches  long. 
This  rubber  tube  is  clamped  shut  with  an  artery  forceps 
while  the  blood  is  being  aspirated  from  the  donor.  The 
forceps  is  removed  and  clamped  above  the  tee  when  the 
transfusion  tube  is  filled  and  inserted  in  the  vein  of  the 
patient. 

Sterilizing  and  Coating  Transfusion  Tube. — Caution: 
Tube  must  be  dry  and  free  from  blood.  (After  use,  wash 
quickly  with  cold  water  adding  shot  if  necessary  to  loosen 
clots,  then  wash  with  alcohol  and  ether  separately  and 
successively.) 

1.  Dry  Heat  Method. — Wrap  tube  in  a  white  cloth, 
steriUze  in  bacteriological  steriUzer  by  dry  air,  30  minutes 
at  175°  C.  Caution. — Do  not  overheat.  Before  tube  be- 
comes cold  pour  in  a  couple  of  ounces  of  melted  and  steril- 
ized ordinary  hard  grocer's  paraffin.  Turn  tube  around 
(handhng  it  with  sterile  gloves  or  scrubbed  hands)  so  that 


488  CANCER  OF  THE  STOMACH 

every  part  is  reached  by  the  melted  paraffin.  The  paraffin 
is  then  poured  out  of  the  large  end  of  the  tube.  Examine 
canula  (small  end)  to  make  sure  that  it  is  not  closed  by  the 
hardened  paraffin.  It  should  be  T\'ide  open.  If  not,  heat 
gently  over  escaping  steam  or  a  small  flame  and  tip  the  tube 
so  that  the  paraffin  runs  out  into  the  large  end  of  the  tube. 
The  tube  may  then  be  safely  done  with  cold  air,  fanning  it 
or  by  pouring  over  it  sterile  water,  first  warm  then  cooler 
and  cooler.  (No  water  should  reach  the  inside  of  the  tube 
as  it  will  not  then  coat  over  evenly.) 

2,  Steam  or  Autoclave  Method. — Aspirate  or  pour  about 
2  ounces  of  melted  grocer's  paraffin  into  tube  (dry  and  free 
from  blood),  wrap  loosely  in  a  towel  or  cloth,  sterilize  15 
minutes  only  at  15  pounds  pressure  in  the  autoclave. 
Turn  the  tube  around  so  that  every  part  of  the  tube  is 
reached  b}^  the  paraffin,  handling  it  with  sterile  gloves  or 
scrubbed  hands.  The  process  of  cooUng  is  as  described 
in  the  previous  method.  The  tube,  properly  coated,  has  a 
uniform  gray  color  and  the  canula  is  wide  open.  The  tube 
is  now  ready  for  use  and  may  be  wrapped  up  in  a  sterile 
towel  and  put  away. 

SterHizing  rubber  tubing,  glass  tee,  and  mouthpiece  is 
done  by  pulling  them  apart,  wrapping  them  in  a  towel 
(careful  not  to  have  any  kinks  in  the  tubing)  and  sterihzing 
in  the  autoclave  15  pounds  pressure  for  15  minutes.  (Note. 
— Use  no  heat  for  sterihzing  rubber  bulb.  Wash  with 
alcohol  before  using;  this  is  sufficient.)  A  small  arteTj 
forceps  is  clamped  on  the  rubber  tube  between  the  atomizer 
bulb  and  the  glass  tee.  A  small  piece  of  sterile  cotton  is 
inserted  into  the  glass  tee,  the  rubber  tube  connected  with 
the  mouthpiece  is  then  slipped  over  one  branch  of  the  tee,  the 
atomizer  bulb  is  connected  to  the  side  branch  of  the  tee  and 
the  rubber  remaining  connects  the  other  branch  of  the  tee 


XOX-SURGICAL    TREATMENT  489 

to  the  mouth  of  the  transfusion  tube.  The  mouthpiece  at 
the  free  end  of  the  rubber  tube  is  now  placed  in  the  mouth 
and  an  ounce  of  sterile  Uquid  parafhn  is  then  sucked  up 
through  the  canula  tube  into  the  tube.  The  mouthpiece 
is  then  wrapped  in  sterile  gauze  so  as  not  to  contaminate 
the  sterile  tube.  The  whole  is  then  set  aside  ready  for  use. 
The  hquid  paraffin  floating  on  top  of  the  blood  prevents  the 
access  of  ah-,  thus  tending  to  delay  coagulation. 

Procedure. — A  constrictor,  which  may  be  a  rubber  tube 
but  better  a  blood-pressure  instrument,  for  the  donor  is 
placed  high  around  the  arm.  The  veins  of  the  arm  of  donor 
and  recipient  are  exposed,  preferably  above  the  elbow. 
The  incision  is  best  made  from  2  to  3  inches  long  just  above 
the  bifurcation  of  the  median  vein  at  the  elbow.  Two  per- 
cent, cocain  is  injected  about  the  vein  hyiDodermically. 
The  vein  is  carefully  dissected  out,  the  small  branches  being 
clamped,  ligated,  and  divided. 

Up  to  this  point  the  operation  is  the  same  in  the  case  of 
both  donor  and  patient.  The  operation  should  be  com- 
pleted to  this  extent  in  both  persons  before  the  vein  is 
opened  in  either  case. 

A  ligature  is  then  placed  around  the  vein  of  the  donor  at 
its  upper  end.  that  is  centrally,  and  tied,  another  ligature 
is  placed  at  the  lower  part  and  not  tied  but  held  by  the 
assistant  before  and  while  the  vein  is  being  opened  by  the 
operator,  in  order  to  control  bleeding  while  the  canula  is 
being  inserted.  Similarly  a  hgatm^e  is  placed  around  the 
vein  of  the  patient  and  tied  at  the  distal  part,  another  being 
sUpped  around  the  vein  centrally  and  held  without  t}T.ng 
while  this  vein  is  opened  and  the  canula  inserted.  Both 
veins  are  now  opened  between  the  hgatiu'es  placed  as  above, 
with  a  sharp  scalpel  or  fine  sharp  scissors.  A  T^ide  and  free 
opening  must  be  made  in  the  vein  in  order  that  the  canula 


490 


CANCER    OF   THE    STOMACH 


may  slip  easily  into  the  lumen  of  the  vein.  It  is  very  easy 
to  slip  the  canula  between  the  walls  of  the  vein  instead  of 
into  the  lumen  if  this  precaution  is  not  observed. 

The  transfusion  tube  now  contains  an  ounce  of  Uquid 
paraffin  in  it  and  with  atomizer  bulb  clamped  off,  is  taken 
up  by  the  assistant.     The  mouthpiece  is  placed  in  his 


Fig.  105. — Transfusion  by  Percy-Cook  method.  Illustration  shows  end 
of  tube  in  position  for  aspirating  blood  from  vein  of  donor.  _  Note  paraflfin- 
lined  tube,  layer  of  liquid  paraffin  above  blood  level.  Aspirating  tube  and 
clamp  on  tube  leading  to  compression  bulb. 

mouth,  the  upper  end  of  the  tube  balanced  in  his  hand  while 
the  operator  sUps  the  canula  into  the  vein  of  the  donor  in  a 
distal  direction,  i.e.,  toward  the  hand.  If  the  canula  does 
not  sUp  readily  into  the  vein,  this  may  be  facihtated  by 
grasping  and  holding  apart  the  edges  of  the  cut  vein  with 
fine  mouse-tooth  or  smaU-nosed  docking  forceps,  or  the 
canula  may  be  guided  along  the  channel  of  a  grooved  direc- 


NON-SURGICAL    TREATMENT 


491 


tor,  which  has  been  sHpped  into  the  vein.  The  canula  is 
pushed  home  into  the  vein  until  its  tapering  sides  just  fill 
the  lumen  of  the  vein.  The  distal  ligature  is  then  loosened 
and  the  air-pressure  constrictor  pumped  up  to  60  to  90  mm. 
The  blood  quickly  gathers  from  the  anastomosing  deep  and 
superficial  veins  and  flows  through  the  open  vein  into  the 


Fig.  106. — Percy-Cook  method  of  blood  transfusion.  Blood  being  given 
to  recipient.  Note  direction  of  transfusion  tip  in  arm  vein;  clamp 
on  aspiration  tube  with  compression  bulb  under  control  for  gradually 
emptying  transfusion  tube. 

canula.  The  assistant  then  sucks  gently  but  continuously 
and  the  blood  rapidly  enters  the  tube.  (Too  hard  sucking 
will  collapse  the  vein  so  that  no  blood  enters  the  tube.)  If 
the  vein  has  been  pulled  too  hard  by  the  assistant  holding 
the  ligature  it  will  collapse  much  more  quickly.  If  the  tech- 
nique has  been  good  the  tube  may  be  filled  in  4  or  5  min- 
utes.    It  is  not  advisable  to  leave  the  canula  in  the  vein 


492  CANCER  OF  THE  STOMACH 

for  a  much  longer  time,  however.  It  is  better  to  be  content 
with  taking  200  or  300  cc.  of  blood  than  take  6  or  7  minutes 
to  fill  the  tube.  The  rubber  tube  is  now  clamped  with  a 
heavy  artery  forceps  near  the  mouth  of  the  transfusion  tube 
in  order  that  blood  shall  not  be  lost  in  the  transfer  from 
donor  to  patient.  The  canula  is  then  taken  out  and  in- 
serted in  the  vein  of  the  patient  in  a  central  direction,  i.e., 
toward  the  heart.  The  large  clamp  is  removed  from 
the  rubber  tube  near  the  mouth  of  the  transfusion  tube. 
The  small  clamp  near  the  atomizer  bulb  is  taken  off  and 
clamped  above  the  glass  tee  and  between  it  and  the  mouth- 
piece. Gentle  pressure  is  now  placed  upon  the  atomizer 
bulb  which  forces  the  air  into  the  tube,  displacing  the  blood 
as  it  enters  the  vein.  It  should  take  about  4  to  5  minutes 
to  inject  the  blood  as  a  more  rapid  injection  may  cause  a 
dilatation  of  the  right  heart  with  collapse  and  death.  (After 
taking  the  canula  from  the  donor's  vein  an  assistant  mean- 
while removes  the  constrictor  from  the  arm  and  ties  the 
distal  ligature  of  the  donor's  vein.)  The  canula  must  be 
slipped  out  before  any  liquid  paraffin  enters  the  vein  pro- 
ducing fat  emboli.  When  this  is  done  the  central  ligature 
on  the  patient's  vein  is  tied  and  the  skin  closed  over  the 
vein  with  horse-hair  stitches. 

Advantages  of  the  Method. — 1.  The  blood  is  measured  and 
a  definite  quantity  is  taken  and  injected  in  a  short  space 
of  time. 

2.  The  donor  is  protected  absolutely  from  any  infection 
which  the  patient  may  have,  as  there  is  no  contact,  direct 
or  indirect.  There  is  no  chance  for  a  drop  of  the  patient's 
blood  to  get  into  the  donor's  vessels. 

3.  It  is  a  venous  operation,  so  there  is  no  danger  from 
infection  to  the  deep  structures  lying  about  the  large  artery 
usually  used  for  the  purpose.     There  is  no  impairment  of 


NON-SURGICAL   TREATMENT  493 

the  circulation  as  from,  the  Hgation  of  such  an  important 
artery  as  the  radial. 

4.  It  has  proved  uniformly  successful  where  care  has 
been  taken  to  insure  the  proper  technique. 

In  the  treatment  of  the  anemia  following  gastric  hemor- 
rhage or  gastric  seepage,  the  most  satisfactory  remedies  ap- 
pear to  be  salvarsan,  arsenious  acid,  Fowler's  solution  or 
cacodylate  of  sodium.  Any  of  these  may  be  given  alone, 
or  with  preparations  of  iron.  There  are  numerous  useful 
iron  preparations.  We  have  found  to  be  of  service,  Blaud's 
mass  or  various  forms  of  iron  conveniently  put  up  in  ampules 
for  hypodermatic  administration. 

There  are  many  cases  of  malignant  anemia  in  which 
ordinary  drugs  are  of  little  value.  In  such  cases  if  the  stool 
examination  reveals  the  constant  presence  of  altered  blood, 
the  giving  of  blood-building  medicines  may  become  effective 
after  several  hypodermic  injections  of  horse  serum  or  a 
transfusion  of  from  300  to  600  cc.  of  human  blood.  Not 
rarely,  attention  to  these  details  will  enable  the  patient  to 
come  to  operation,  or  will  render  operative  procedures  of 
more  marked  benefit. 

X-rays. — In  gastric  cancer,  the  therapeutic  value  of 
Roentgen  rays  is  uncertain.  The  effects  appear  to  be 
largely  influenced  by  the  type  of  gastric  neoplasm,  the  stage 
of  the  disease,  the  pressure  of  associated  lesions  (anemia, 
metastases,  cardiorenal  complications  and  the  like),  and 
the  skill  with  which  treatments  are  given. 

Cases  in  which  the  method  appears  to  be  justifiable  are 
those  where  inoperable  growths  exist;  where  operation  has 
been  performed  and  gland  involvement  discovered;  where 
patients  are  either  too  weak  for,  or  refuse,  surgical  inter- 
vention; where  recurrences  have  appeared,  and  in  the  in- 
terim of  two-stage  operations. 


494  CANCER    OF    THE    STOMACH 

It  should  he  especially  emphasized  that  under  no  circum- 
stances other  than  absolute  refusal  of  surgical  measures,  should 
x-ray  therapy  he  advised  in  instances  of  suspected  or  early 
gastric  malignancy.  It  is  the  phj^sician's  duty  to  urge  the 
benefits  of  laparotomy.  There  is  no  instance  of  pathologic- 
all}^  demonstrated  gastric  cancer,  on  record,  that  has  been 
cured  by  x-v3cy  treatments. 

In  suitable  instances,  x-ray  exposures  may  be  begun 
2  or  3  days  following  laparotomy.  Treatment  should  be 
to  the  deeper  tissues,  with  a  hard  tube,  and  there  should  be 
(except  in  Y&ry  weak  patients,  or  those  who  have  previously 
been  treated  by  .x-rays)  exposure  of  from  1.5  minutes  to 
1  hour.  The  parts  of  the  body  adjacent  to  the  treatment 
area  must  be  carefully  protected  by  lead  foil.  Such  pro- 
cedure insures  proper  ^'erj^thema  dose."  The  treatments 
should  be  given  dailj^,  or  every  other  day  for  from  6  to  12 
days.  A  rest  of  a  similar  period  should  be  permitted 
before  the  patient  is  again  exposed. 

During  actinotherapy  frequent  examination  of  the  pa- 
tient's urine  and  blood  should  be  made.  Vigorous  a;-ray 
treatment  is  not  infrequently  accompanied  by  the  presence 
of  albumin  and  casts  in  the  urine.  Rapid  destmction  of 
red  blood  ceUs,  with  a  fall  in  the  hemoglobin  and  an  increase 
of  mononuclear  leucocytes  at  the  expense  of  the  polynuclear 
forms  may  follow  prolonged  Roentgen  exposure. 

The  precise  way  in  which  x-ray  therapy  favorably  influ- 
ences certain  malignant  growths  is  not  known.  It  would 
appear  that  the  x-rays  may  destroy  young  cancer  cells, 
split  cancer-protein  into  ''toxic"  and  "'non-toxic"  mole- 
cules, cause  hemorrhage  with  liberation  of  enzymes  capable 
of  attacking  neoplastic  ceUs,  or,  by  stimulating  some  yet 
undiscovered  property'  of  the  blood  serum,  formed  elements 
or  both,  strengthen  the  body's  defensive  mechanism. 


NON-SURGICAL    TREATMENT  495 

Radium,    Mesothorium    and    Allied    Substances. — In 

growths  of  limited  extent,  particularly  when  such  are 
located  at  or  near  the  cardia,  it  would  seem  that  radium  or 
mesothorium  are  of  value.  Such  may  be  applied  directly 
to  the  diseased  area  in  protected  capsules  at  the  ends 
of  sounds.  The  capsule  should  be  left  in  situ  for  from  1 
to  12  hours.  Only  wealthy  folks  are  able  to  afford  such 
treatments. 

Where  there  is  extensive  involvement  of  the  stomach  by 
cancer,  we  have  observed  certain  interesting  results  follow- 
ing the  drinking  of  radio-active  water.  If  from  4  to 
60  cc.  are  administered  at  intervals  of  from  1  to  4  times 
daily,  pain  appears  to  lessen  or  subside,  the  stomach  con- 
tents become  less  foul,  hemoglobin  may  increase,  and  the 
patient  may  exhibit  an  attitude  of  general  well-being.  Oc- 
casionally, the  disease  appears  to  remain  quiescent  for  a 
time,  or  it  progresses  slowly.  Massmann  reports  an  in- 
stance where  cancer  at  the  cardiac  orifice  was  held  in 
check  for  2  years  by  the  ingestion  of  radio-active  water. 
The  patient  finally  succumbed  as  the  result  of  metastases. 

Radio-active  water  has  at  least  the  quality  of  being 
comparatively  reasonable  in  price.  Its  extensive  use  is 
thus  possible. 

It  should  not  be  forgotten  that,  due  to  much  pseudo- 
scientific  publicity,  and  to  the  cost  of  treatments  by  x-ray, 
radium  or  mesothorium,  a  not-to-be-neglected  benefit  that 
may  accrue  from  their  use,  has  a  psychic  foundation.  If 
the  patient  can  afford  such  comfort  he  should  be  permitted 
it.  On  the  other  hand,  no  sacrifice  or  neglect  of  simple, 
proved  and  accessible  therapeutic  measures  should  be  per- 
mitted in  order  that  a  patient  enjoy  light  therapy.  Not 
rarely  do  we  see  individuals  who  have  spent  their  all  pur- 


496  CANCER   OF   THE    STOMACH 

suing  phantom  cures,  die  in  squalor  or  become  a  burden 
upon  the  commonwealth,  or  upon  charitable  friends. 

Serotherapy. — In  1909,  Hodenpyl  reported  striking  re- 
sults in  malignancy  following  the  injection  into  those 
affected,  of  ascitic  fluid  obtained  from  the  peritoneal  sac  of 
a  woman  in  whom  there  seemed  to  have  been  a  spontaneous 
cure  of  an  intra-abdominal  neoplasm.  Unfortunately,  both 
the  donor  of  the  serum  and  the  brilliant  investigator  died 
when  it  seemed  about  to  be  shown  that  serum  from  certain 
kinds  of  cancer  appeared  to  possess  protective  substances. 
R,.  Weil  made  an  extensive  biochemic  examination  of  the 
Hodenpyl  fluid  and  showed  that  it  seemed  to  contain  a 
measurable  increase  of  anti-cancer  bodies. 

Other  antisera  have  been  proposed.  The  most  notable  of 
these  is  that  of  Berkeley  and  Beebe.  These  investigators 
claim  to  have  made  an  extract  of  cancer  tissue  removed 
surgically.  By  successive  injection  of  the  ''specific  human 
cancer  extract"  into  alien  mammals,  a  serum  may  be 
developed  which  when  injected  into  the  original  host  in 
increasing  doses,  is  followed  by  ''rapid  regression  and  dis- 
appearance" of  what  tumor  remains.  Berkeley  and  Beebe 
think  the  effect  is  due  to  cytolysis  of  the  tumor  cells.  They 
report  encouraging  results  from  the  use  of  their  "anti- 
serum" in  16  cases  of  malignancy. 

Autolysates  of  human  embryos  have  been  used  by  Fischera 
in  the  treatment  of  malignancy.  Nearly  50  per  cent,  of 
his  cases  were  aided  by  the  treatment. 

Vaccine  Treatments. — This  method  of  therapy  has  been 
frequently  suggested,  and  all  types  of  vaccines  have  been 
used.  If  removal  of  a  metastatic  gland  shows  sarcoma, 
then  a  certain  beneficial  effect  may  result  from  the  use  of 
Coley's  "toxins"   {Streptococcus   erysipelatis  and  Bacillus 


NON-SURGICAL   TREATMENT  497 

prodigiosus) .  This  remedy  should  be  tried  whenever  it  is 
possible. 

Suggestive  "spUt-proteid^'  vaccination  has  been  carried 
on  by  W.  Vaughan  in  cases  of  cancer.  Basing  his  work 
upon  the  investigations  of  V.  C.  Vaughan  on  cellular  pro- 
teids,  W.  Vaughan  has  prepared  a  "vaccine"  consisting  of 
aqueous  solutions  of  the  non-toxic  radicle  of  the  protein 
molecule.  W.  Vaughan  describes  the  preparation  of  this 
vaccine  as  follows: 

A  small  piece  of  the  tissue  is  first  examined  by  frozen 
section,  in  order  to  ascertain  the  exact  nature  of  the  growth. 
Next,  the  malignant  tissue  is  dissected  as  freely  as  possible 
from  all  surrounding  tissues,  after  which  it  may  be  placed 
in  absolute  alcohol  and  kept  until  opportunity  is  given  to 
carry  out  the  following  steps.  All  tissue  should  be  dehy- 
drated in  absolute  alcohol  before  being  split  up.  Next, 
the  cancer  material  is  ground  as  finely  as  possible  with  an 
ordinary  meat  grinder,  but  if  the  amount  is  small,  loss  may 
be  saved  by  cutting  with  scissors  and  forceps,  after  which 
it  is  placed  in  a  flask  which  contains  about  15  times  the 
volume  of  material  of  a  2  per  cent,  solution  of  sodium 
hydrate  in  absolute  alcohol.  (It  will  facilitate  the  solu- 
tion of  the  sodium  hydrate  in  the  alcohol  if  the  former  is 
first  pulverized  finely  in  a  mortar.)  The  flask  containing 
the  material  is  next  heated  over  a  water-bath  for  from  2  to 
3  hours,  depending  on  the  amount  of  tissue  that  is  to  be 
split  up.  For  safety  only,  the  flask  is  connected  with  some 
form  of  condenser  before  heating.  However,  the  alcohol 
should  not  be  heated  to  such  a  degree  that  it  actively  dis- 
tils, as  too  much  heat  will  absolutely  destroy  the  activity 
of  the  resulting  residue.  At  the  end  of  2  or  3  hoiu-s  the 
tissue  within  the  flask  should  appear  as  a  finely  divided 
powder.     If  this  is  not  the  case  it  is  my  practice  to  allow 

32 


498  CANCER  OF  THE  STOMACH 

the  flask  to  stand  over  night,  after  which  time  the  super- 
natant fluid  is  decanted  and  a  sufficient  amount  of  the  alka- 
line alcohol  solution  added  to  make  up  the  original  volume, 
heat  being  again  applied  in  the  same  manner. 

Next  the  solution  is  filtered  off  and  the  residue  washed 
upon  the  filter  with  absolute  alcohol  until  its  reaction  is  no 
longer  alkaline.  While  still  somewhat  moist  the  residue  is 
weighed  upon  the  filter,  a  filter  paper  of  equal  weight  being 
placed  upon  the  opposite  balance  to  offset  the  weight  of  the 
one  containing  the  residue.  Next  it  is  transferred  with  a 
sterile  spatula  to  a  sterile  bottle  and  sufficient  sterile  water 
added  to  make  the  desired  solution.  With  small  amounts 
of  material  I  prefer  a  1  per  cent,  solution,  with  larger 
amounts,  a  2  per  cent.  Practically  all  of  the  residue  is 
soluble  in  water,  but  if  such  is  not  the  case  it  may  be  filtered. 
Lastly,  sufficient  phenol  is  added  to  make  the  given  amount 
contain  0.5  per  cent.  This  is  kept  as  stock  solution  and 
injections  given  of  the  same. 

W.  Vaughan  states  that  injections  of  from  3  to  30  cc. 
of  his  solution  may  be  made  frequently.  The  time  for 
injection  is  indicated  by  observing  the  relative  fluctuations 
of  the  polymorphonuclear  and  the  mononuclear  cells  in 
differential  blood  counts.  An  increase  in  mononuclear 
cells — particularly  of  the  large  mononuclears — appears  to 
be  a  favorable  sign.  The  injections  should  be  given  ''only 
at  the  periods  during  which  the  percentage  of  polymorpho- 
nuclear leucocytes  is  increasing." 

W.  Vaughan  reports  numerous  cases  illustrative  of  the 
effects  of  using  spUt-proteid  vaccine.  Some  have  encour- 
aging pointings.  W.  Vaughan's  contributions  to  the  effect 
of  cancer  residue  injections  upon  blood  morphology  are 
certainly  creditable  and  perhaps  not  without  practical 
significance. 


XOX-SURGICAL   TREATMENT  499 

Chemo -therapy. — The  announcement  by  Wassermann 
that  solutions  of  an  eosin-selenium  compound  brought 
about  regression  or  even  cure  of  cancers  in  mice  proved  a 
rare  stimulus  to  workers  in  experimental  laboratories  and 
to  clinicians.  Notable  reports  have  come  from  EhrUch, 
Caspari,   Xeuberg  and  Popov. 

These  investigators  have  shown  that  certain  cancers  are 
cured,  regress,  or  have  their  growth  halted  when  intravenous 
injections  of  solutions  of  colloidal  copper,  platinum  or 
selenium,  eosin-selenium  compounds,  leech  extract  or  casein 
are  given.  Robertson  and  Burnett  have  observed  that 
aqueous  emulsions  of  lecithin  injected  directly  into  tumors 
diminish  the  tendency  to  form  metastases,  retard  the  metas- 
tatic growth  when  it  does  occur,  and  in  some  instances 
retard  the  primary^  growth. 

It  would  appear  that  treatment  of  cancer  by  chemo- 
therapy offers  alluring  possibilities.  The  method  has  not 
yet  proven  of  absolute  worth.  It  is  suggested  that  direct 
injection  of  solutions  of  coUoidal  copper  or  platinum,  leech 
extract,  casein  or  emulsions  of  lecithin  into  irremovable 
gastric  cancers  or  metastases  from  such  might  be  employed 
with  benefit. 

REFERENCES 

Berkeley  and  Beebe:  New  York  Medical  Record,  1912,  March  16. 

Vaughax,  W.:  N.  Y.  Med.  Jour.,  1910,  Oct.  15. 

Caspari  and  Netjeerg:  Deutsck.  ISIed.  'Wockenschr.,  1912,  Vok 
xxxviii,  p.  375. 

Popov:  These  de  Unirersite  de  !MontpeHer,  1913,  July  26,  Xo.  24. 

LoEB,  McClurg,  and  Sweek:  Loeb  and  Fleisher;  Loeb,  IMcClurg  and 
Sweek;  and  Loeb  and  Fleisher,  Jour.  A.M.A.,  1913,  June  1-i,  p.  1857, 
and  The  Interstate  Medical  Journal,  1912,  vol.  xix,  Xo.  12. 

Loeb:  Interstate  Medical  Journal,  1913,  xx,  Xo.  5. 

Robertson  and  Burnett;  Jour,  of  Exp.  Med.,  1913,  Xo.  3,  p.  34-4. 


INDEX  OF  NAMES 


Abderhaldex,  230,  266,   320,  344,       DaCosta,  327 


347,  349 
Adami,  371,  372 
Aschoff,  31,  50 
AscoK,  320,  348,  349 
Ascoli  and  Izar,  349 

Bashfoed,  96 

Beck,  421 

Beebe  and  Berkeley,  496,  499 

Bergmann  and  Meyer,  342,  344,  349 

Berkeley  and  Beebe,  496,  499 

Bernstein  and  Simons,  348,  349 

Blackford  and  MacCarty,  105,  109, 

362 
Blumer,  184, 185,  186 
Boas,  205 

Boas  and  Oppler,  211 
Bolton,  351,  352,  371 
Bonhoff,  332,  349 
Brinton,  26,  50,  98,  109,  175,  351, 

369,  371,  372 
Broders  and  ^MacCarty,  109 
Buday,  18,  50 
Burnett  and  Robertson,  499 

C.a:bot,  24,  50,  324,  326,  327,  329,  349 

Cammidge,  263,  267 

Campbell,  52,  108,  412 

Capps,  332 

Carrel,  85,  109 

Caspari,  499 

Chesnel,  358,  372 

Clendenning,  52,  108,  412 

Clowes,  486 

Coley,  496 

Connell,  425,  434,  436,  451,  452,  461, 

463 
Cook  and  Percy,  475,  486,  490,  491 
Coolidge,  276 
CrHe,  336 
Cuneo,  418 
Cunliffe,  327,  349 


Dare,  115,  127,  138,  324 

Dittrich,  98 

Dobell,  475 

Dock,  173,  373,  374,  381,  406,  416 

Drew,  371,  372 

Ehelich,  499 

Elsberg,  Xeahoff  and  Geist,  338,  349 

Eisner,  190 

Emerson,  242,  267 

Ewald,  245,  246 

FeilDstein  and  Weil,  344,  349 
Fenwick,  24,  26,  37,  38,  44,  48,  50, 

52,  98,  107,  108,  109,  134,  147, 

175,  361,  372 
Fibiger,  39,  50,  84,  109 
Fischer,  230,  266 
Fischer  and  Xeubauer,  230,  231,  232, 

266 
Fischera,  496 
Fleisher  and  Loeb,  499 
Flexner  and  JobUng,  83 
Fonio,  227 
Forametti,  190 
Fox,  26,  50 

Frank  and  Heimann,  347,  349 
Franz,  347,  349 
Frazier,  52,  108 
Frennd  and  Kaminer,  339,  349 
Friedenwald,  26,  28,   50,   175,   356, 

363,  364,  372 
Fuld  and  Levison,  228,  229,  266 
Fiitterer,  39,  50 

Galtox,  44,  50 

Gay,  85,  109,  320 

Gaylord,  480 

Geist,  Elsberg,  and  Xeuhoff,  338,  349 

Gies,  239,  267 

Gluzinski,  226 

Graham,  355,  363,  371,  372 


502 


INDEX   OF   NAMES 


Gressot,  359,  372 
Gross,  263 
Gunzberg,  202 

Hahn,  175 
Hall,  190 

Hall  and  Williamson,  231,  267 
Hamburger,  320 
Hansmann,  366 

Hardisty  and  Ruttan,  205,  266 
Hardy  and  Meyer,  411 
Heimann  and  Frank,  347,  349 
Hendly,  37 
Hie  Ding  Lin,  31 
Hodenpyl,  496 

Hoffman,  20,  21,  23,  25,  28,  29,  34, 
35,  50 

IzAR  and  Ascoli,  349 

Jackson,  190 

Jacques  and  Woodyatt,  367,  372 

Janeway,  190 

Jobling,  320 

JobUng  and  Flexner,  83 

Jones  and  Rous,  108 

Junghans  and  Wolff,  117,  142,  143, 
146,  245,  246,  247,  248,  250, 
251,  252,  253,  254,  255,  256, 
267,  368,  398 

Kaminer  and  Freund,  339,  349 
Kauffmann,  211,  266 
Kausch,  190 
KeUing,  190,  348,  349 
Kober  and  Lyle,  231,  266 
Kocher,  438,  439 
Kohlenberger,  231,  266 
Krida,  334,  335,  336,  338,  349 
Kussmaul,  171,  389,  397 
Kuttner,  190 

Lane,  469 

Lang,  334,  349 

Lebert,  98,  175,  369,  372 

Lembert,   435,   436,   438,   449,   450, 

452,  453,  458,  461,  462,  463 
Leube,  175 

Levin,  83,  108,  371,  372 
Levison  and  Fuld,  228,  229,  266 


Loeb,  499 

Loeb  and  Fleisher,  499 

Loeb,  McClurg,  and  Sweek,  499 

Louis,  98 

Luton,  98,  109 

Lyle,  412 

Lyle  and  Kober,  231,  266 

MacCarty,  68,  77,  85,  86,  87,  88, 

109,   238,   352,   353,   370,  371, 

372 
MacCarty  and  Blackford,  105,  109, 

362 
MacCarty  and  Broders,  109 
MacCarty  and  Wilson,  67,  69,  70, 

71,  72,  73,  74,  75,  76,  109,  269, 

358,  370,  372 
Massmann,  495 
Mathieu,  374,  381 
.  Mayo  (C.  H.),  437 
Mayo  (W.  J.),  428 
Mayo-Robson  and  Moynihan,  50 
McClurg,  Loeb,  and  Sweek,  499 
McCrae  and  Osier,  38,  50,  175,  321, 

324,   326,   329,   332,   349,   356, 

372,  373,  381 
McDowell  and  Wilson,  370 
Melinkow,  370 
Metchnikoff,  486 
Meyer,  421 

Meyer  and  Bergmann,  342,  344,  349 
Meyer  and  Hardy,  411 
Mikulicz,  190 
Miyake,  31,  50 
Moniciion,  44,  50 
Moreschi,  97,  109 
Morris,  109 
Morris  (Roger),  106 
Moynihan  and  Mayo-Robson,  50 
Mtiller,  230,  266,  332,  339,  349 
Miiller  and  Whitman,  342,  344,  347 
Murphy,  81,  85,  108,  459,  481 
Murphy  and  Rous,  109 
Murphy,  Rous,  and  Tytler,  108 

Napoleon,  123 

Neubauer  and  Fischer,  230,  231,  232, 

266 
Neuberg,  499 
Neuhoff,  Elsberg  and  Geist,  338,  349 


INDEX   OF   NAMES 


503 


OcHSNER,  33,  417,  480 

Oppenheim,  231,  266 

Oppler  and  Boas,  211 

Osier,  48,  358,  372 

Osier  and  McCrae,  38,  50,  175,  321, 

324,   326,   329,   332,   349,    356, 

372,  373,  381 

Pateeson,  359,  372 

Pelosi,  227,  266 

Percy  and  Cook,  475,  486,  490,  491 

Petry,  342 

Pettinkofer,  243 

Popov,  499 

Ransohopf,  348,  349 

Robertson  and  Burnett,  499 

Roche,  344,  349 

Rokitansky,  108 

Rokitansky  and  Waldeyer,  52 

Rolph,  246,  267 

Rosenbloom  and  Sanford,  231,  239, 

267 
Rosenheim,  190,  361,  372 
Rous,  81,  85,  95,  97,  108,  109 
Rous  and  Jones,  108 
Rous  and  Murphy,  109 
Rous,  Murphy,  and  Tytler,  108 
Ruttan  and  Hardisty,  205,  266 

Salomon,  245 

Sanford  and  Rosenbloom,  231,  239, 

267 
Schiff  and  Sorenson,  138,  142,  229, 

252,  266,  367,  372 
Schoenberg,  276 
Schryver  and  Singer,  202,  203,  228, 

229.  266 
Senn,  423 
Shutz,  356,  372 

Simons  and  Bernstein,  348,  349 
Singer  and  Schryver,  202,  203,  228, 

229,  266 
Slye,  45,  50 
Smith,  83,  108,  480 
Snow,  83,  108 
Sorenson  and  Schiff,  138,  142,  229, 

252,  266,  367,  372 
Stockton,  344,  349 


Strauss,  204,  226,  366 

Sussmann,  190 

Sweek,  Loeb  and  McClurg,  499 

TALLQtnST,  115,  118 

Tatham,  31,  50 

Topfer,  366 

Traube,  188 

Tytler,  Rous,  and  Murphy,  108 

Uffelmann,  226,  242,  379 

Vaughan",  147 
Vaughan  (V.  C),  497 
Vaughan  (W.),  497,  498,  499 
Virchow,  45,  50,  52,  108,  111,  184 
Virchow  and  Waldeyer,  111 

Waldeyer,  52  ,79,  108,  111 
Warfield,  231,  239,  240,  266,  338,  349 
Wassermann,  396,  410,  499 
Weil,  320,  334,  349,  496 
Weil  and  Feldstein,  344,  349 
Weinstein,  231,  233,  239,  241,  266, 

267 
Welch,  26,'50,  98,  100,  109,  327,  369, 

372,  373,  381 
Whitman,  342,  349 
Whitman  and  IMliller,  342,  344,  347 
Williams,  31,  33,  34,  37,  44,  48,  50 
Williamson  and  Hall,  231,  267 
Wilson,  89,  90,  91,  92,  107,  109 
Wilson  and  MacCarty,  67,  69,  70, 

71,  72,  73,  74,  75,  76,  109,  269, 

358,  370,  372 
Wilson  and  McDowell,  370 
Witzel,  422,  423 
Wohlgemuth,  261,  263,  267 
Wolff,  248 
Wolff  and  Junghans,  117,  142,  143, 

146,   245,   246,   247,   248,   250, 

251,   252,   253,   254,   255,   256, 

267,  368,  398 
Woodyatt  and  Jacques,  367,  372 
Wooley,  371,  372 
Wynhausen,  263,  267 

Yates,  52,  108,  412 


INDEX 


Abderhalden  method  for  detection 
of    specific    ereptases, 
344 
apparatus  for,  345 
technique  of,  347 
Abdominal  examination,  166 
catharsis  before,  167 
gastric  lavage  before,  167 
position  of  patient  for,  168 
preparation  of  patient  for,  167 
inspection,  169 

change  of  position  in,  170 
enlarged  lymph  nodes  in,  172 
local  prominences  in,  169 
pelvic  bones  in,  169 
presence  of  free  fluid  in,  169 
respiratory  movements,  in,  170 
rib  margins  in,  169 
visible  peristalsis  in,  170 
pain,  132,  149 
palpation,  172 

after  inflation  of  stomach,  177 
appearance  of  skin  in,  173 
deep,  174 

diminished   tension   of  abdom- 
inal wall  in,  172 
hot  bath  before,  173 
parietes,   thickness   of,   effect   on 
palpation  of  abdominal  tumors, 
183 
prominences,  local,  169 
tumor,  154,  175 

effect  of  gastric  inflation  on,  182 
of  respiratory  movements  on 
mobihty  of,  183 
incidence,  175 
mobihty  of,  179 

influence  of  complications  on 
demonstration  of,  181 
of  duration  of  disease  on 

demonstration  of,  180 
of  histologic  type  on  dem- 
onstration of,  180 


Abdominal  tumor,  mobilitj-  of,  influ- 
ence of  location  in  gastric  wall 
on  demonstration  of,  181 

of  position  of   patient    on 
demonstration  of,  181 
palpation     of,     tenderness    [in, 
178 
effect  of  thickness  of  abdom- 
inal parietes  on,  183 
position  of,  176 

relation  to  part  of  stomach 
involved,  177 
size  of,  178 
wall,  tumors  of,  gastric  cancer  and, 
differential  diagnosis,  416 
Abnormal     proliferation     of     gland 

cells,  79 
Abnormahties    in    gastric    outline, 
fluoroscopic  examination  of,  277 
Abscess  of  pancreas,  gastric  cancer 

and,  differential  diagnosis,  401 
Achlorhydria,  Wolff-Junghans'  test 

in,  253 
Achyha    gastrica    associated    with 
gastric  cancer,  47 
gastric  cancer  and,  differential 

diagnosis,  403 
simple,  Wolff-Junghans'  test  in, 

253 
malignant   and  benign,    Wolft'- 
Junghans'  test  in,  246 
Acid   salts   in   gastric  retention  ex- 
tracts, 203 
Acidity,  483 

of  fasting  stomach  extracts,  201 
of  gastric  retention  extracts,  225, 
366 
Gluzinski's  method  of  de- 
termining, 226 
of    stomach    after    operation    for 
gastric  cancer,  466 
Actinomycosis  associated  with  gas- 
tric ulcer,  47 


SOS 


506 


INDEX 


After-treatment    of    complete    gas- 
trectomy, 459 
of   posterior   gastro-enterostomy, 
440 
Age  factor  in  weight  loss,  165 

in  etiology  of  gastric  cancer,  27, 
354 
Air-pressure  cabinet,  Willy  Meyer's, 

421 
Albumin,  precipitible  units  of,  248 
soluble,  Wolff-Junghans'  test  for, 
245,  368 
Alcohol  in  etiology  of  gastric  cancer, 

37 
Alimentation,  duodenal,  478 

metagastric,  478 
Altered  blood,  204.     See  also  Occult 

blood. 
Amount  of  gastric  retention  extracts, 

225 
Anaphylaxis  test,  Ransohoff 's,  348 
Anemia,  125, 154,  319,  365 
causes  of,  320 

following      gastric      hemorrhage, 
treatment  of,  493 
Anemias,  primary,  Wolff-Junghans' 

test  in,  252 
Animals,  experimental  production  of 

gastric  cancer  in,  84 
Anorexia,  114,  482 
Anterior  gastro-enterostomy,  430 
gastrojejunostomy,  429 
wall  of  stomach,  fluoroscopic  ex- 
amination   of    growth    on, 
281 
Roentgenographic       appear- 
ance of  growth  in,  292 
Antitrypsin,  342 

estimation  of,  in  Bergmann  and 
Meyer's  reaction,  343 
Antitryptic  reaction,  Bergmann  and 

Meyer's,  342 
Appearance  of  mucous  membranes, 
319 
of  sclera,  319 
of  skin,  319  . 

Appendix,  disease  of,  association  of 
gastric  ulcer  with,  384 
dyspepsia,    chronic,    in    duodenal 
ulcer,  387 


Appetite,  150 

in  duodenal  ulcer,  389 

in  gastric  cancer  in  young,  376 
Ascites,  163 

in  gastric  cancer,  105 

incidence  of,  in  gastric  cancer,  409 
AscoU's  miostagmin  reaction,  348 
Asiatic  cholera  with  gastric  cancer, 

49 
Asthma  with  gastric  cancer,  50 
Auscultation,  189 
Autolysates,    treatment    of    gastric 

cancer  by,  496 

Bacillus  of  Oppler-Boas,  artificial 
culture  of,  214 
characteristics  of,  212 
cultures  in  beef  bouillon,  216 

after   forty-eight   hours, 

220 
after  seventy-two  hours, 
221 
macroscopic  examination,  222, 

223 
microscopic  examination,  222, 
223 
frequency  of  occurrence,  224 
in  gastric  retention  extracts,  212 
macroscopic  examination,  215 
microscopic  examination,  215 
staining  properties  of,  213 
Bacteria  in  gastric  cancer,  43 

retention  extracts,  211 
Bacterium  tumefaciens,  83 
Basophile  leucocytes  in  gastric  can- 
cer, 332 
Beck's  operation  in  gastric  cancer, 

421 
Benign  and  malignant  growths,  as- 
sociation of,  371 
gastric  cancer,  51 
Benzidin   test  for   occult  blood  in 

gastric  retention  extracts,  205 
Bergmann  and  Meyer's  antitryptic 
reaction,  342 
antitryptic  reaction,  apparatus, 
343 
estimation   of   antitrypsin, 

343 
technique  of,  343 


INDEX 


507 


Bile  coloring  in  gastric  retention  ex- 
tracts, 200 
effect  of,  on  glycyltryptophan  test, 
242 
on  tryptophan  test,  242 
Biliverdin  in  feces,  259 
Bleeding,  125 
Blood,  115,  154 
altered,     204.     See     also     Occult 

blood. 
changes  in  gastric  cancer,  321 
effect     of,     in     glycyltryptophan 
test,  243 
in  tryptophan  test,  243 
in  feces,  259 
in  gastric  cancer,  319 

extracts,     relation     of     Wolff- 

Junghans'  test  to,  255 
clinical  interpretation  of   tests 

for,  260 
in  gastric  cancer  in  young,  379, 
380 
retention  extracts,  204,  226 
benzidin  test  for,  205 
instances  of,  206 
method  of  determining, 
205 
negative  test  for,  261 
serum,    deviations    from    normal 

shown  by,  333 
shadows,  327 

transfusion  by  Percy  and  Cook's 
method,  486 
advantages  of,  492 
technique  of,  489 
tube  used  for,  487 
coating  of,  487 
sterilization  by  dry 
heat      method, 
487 
by  steam  method, 
488 
traumatic,    in     gastric     retention 
extracts,  200 
Blumer's  shelf,  involvement  of,  184 
Bright's  disease  in  gastric  cancer,  50 
Brun's  glucose  medium  for  prepar- 
ing sections  of  cancer  tissue,  108 

Cancer  cases,  registration  of,  474 


Cancer,  gastric,  17.     See  also  Gas- 
tric cancer 
milk,  246 
of  stomach,  17.     See  also  Gastric 

cancer. 
tissue,  preparing  sections,  Brun's 
glucose  medium  for,  108 
Wilson's  rapid  method  of  cut- 
ting and  staining,  107 
Capillary  edema,  319 
Carcinoma  colloides,  58,  94 
fibrosum,  52,  94 

gastric,  52.    See  also  Gastric  cancer. 
meduUare,  53,  94 
of  pancreas,   gastric  cancer  and, 

differential  diagnosis,  401 
of  pylorus,  426 

gastro-enterostomy  for,  427 
two-stage  operation  for,  427 
Carcinomatous  period,  150 

clinical,  130 
Cardia,  growths  near,  diet  in,  477 
fluoroscopic  examination  of,  279 
obstruction  at,  100 
Cardiovascular  disease,  Wolff-Jung" 

hans'  test  in,  254 
Catharsis  before  abdominal  exami- 
nation, 167 
Changes    in    leucocytes,    quantita- 
tive, 327 
Chemical  examination  of  feces,  258 
Chemotherapy  in  treatment  of  gas- 
tric cancer,  499 
Chewing  gum  after  operation,  465 
Cholecystitis  with  gastric  cancer,  48 
CholeHthiasis  with  gastric  cancer,  48 
Chyle,    effect   of,    on    glycyltrypto- 
phan test,  242 
on  tryptophan  test,  242 
Chymification,  presence  of,  in  gas- 
tric retention  extracts,  201 
Cirrhosis  of  liver  with  gastric  can- 
cer, 50 
gastric  cancer  and,  differential 
diagnosis,  411 
Classification  of  gastric  cancer,  51 

neoplasms,  51 
Clinical     consideration     of     gastric 
cancer,  354 
symptoms,  significance  of,  363 


508 


INDEX 


Coagulose,  treatment  of  hemorrhage 

by,  486 
Coley's  toxins,  treatment  of  gastric 

cancer  by,  496 
Colloid  gastric  cancer,  58 
Colon,  excision  of,  in  involvement 

of  transverse  colon  in  gastric  can- 
cer, 469 
Color  of  gastric  retention  extracts, 

200 
Colored   agar  method   for   staining 

gastric  retention  extracts,  208 
Combined  acidity  in  gastric  reten- 
tion extracts,  226 
degree  of,  203 
Complete  gastrectomy,  456 
after-treatment  of,  459 
drainage  after,  458 
Complications,    general,    of    gastric 

cancer,  100 
Conjugal  state  in  etiology  of  gastric 

cancer,  35 
Connell  suture,  425 
Constipation,  114,  125,  150,  484 

chronic,  gastric  cancer  and,   dif- 
ferential diagnosis,  414 

in  gastric  cancer  in  young,  376 
Constitutional  diseases  with  gastric 
cancer,  50 

faults,  gastric  cancer  and,  differ- 
ential diagnosis,  415 
Contracting  gums   after  extraction 

of  teeth,  475 
Cook  and  Percy's  method  of  blood 

transfusion,  486 
Crystals  in  feces,  266 
Curvature,  lesser,  fluoroscopic  exami- 
nation of  growth  in,  279 
Cyst  of  pancreas,  gastric  cancer  and, 

differential  diagnosis,  400 

Decayed  teeth,  161 

Diabetes  with  gastric  cancer,  50 

Diagnosis,  differential,  382 

early,  111 

errors  in,  24 
Diarrhea,  114,  125,  154 

green,  259 
Diastase    in    feces,     Wohlgemuth's 

method  of  determining,  261 


Diet    after    operation    for    gastric 
cancer,  466,  467 
after  posterior  gastro-enterostomy, 

441 
in  etiology  of  gastric  cancer,  35,  477 
in  growths  in  body  of  stomach,  477 

near  cardia,  477 
in  patent  gastric  lumen,  479 
in  pyloric  stenosis,  478 
Differential  diagnosis,  382 
Digestion  leucocytosis,  332 

previous  disorders  of,   in  gastric 
cancer,  355 
Digestive  disorders,  114 
Dilatation  of  stomach,  post-opera- 
tive, 463,  464 
Diphtheria  with  gastric  cancer,  49 
Disease,  duration  of,  148 
Drainage    after    complete    gastrec- 
tomy, 458 
after  excision  of  pyloric  cancer, 
454 
Drug     addictions,     gastric     cancer 

and,  differential  diagnosis,  416 
Duodenal  alimentation,  478 
ulcer,  387 

acid  dyspepsia  in,  387 

appetite  in,  389 

chronic  appendix,  dyspepsia  in, 

387 
dilated  stomach  in,  389 
epigastric  pain  in,  388 

tenderness  in,  389 
eructations  in,  388 
facts  determined  upon  exami- 
nation in,  389 
from  history,  387 
upon    Roentgen    examina- 
tion in,  389 
gastric  cancer  and,  differential 

diagnosis,  391 
glycyltryptophan  test  in,  238 
hematemesis  in,  388 
hemoglobin  in,  389 
hemorrhage  in,  388 
indurated,  360 
melena  in,  388 
pain  time  in,  388 
periodicity  of  complaint,  387 
plethora  in,  389 


INDEX 


509 


Duodenal,  ulcer,  pyrosis  in,  388 
seasonal  relation  of   complaint 

in,  387 
sex  in,  387 

tr^-ptophan  test  in,  238 
vomiting  in,  388 
water-brash  in,  388 
Wolff- Junghans'  test  in,  253 
Duration  of  disease,  148 

influence   of,  on  demonstration 
of     mobility     of     abdominal 
tumor,  180 
of  malignant  period,  132 
Dyspepsia,  acid,  in  duodenal  ulcer, 
387 
cbronic  laparotomy  in,  4:72 
Dysphagia,  114,  147 

Eczema  "with  gastric  cancer,  50 
Edema,  162 

capillary,  319 
Edestin  test  of  Fuld  and  Le^nson, 

228 
Emptj-ing    power,    gastric,    investi- 
gation of,  194 
Enlarged  lymph  nodes  in  abdominal 

inspection,  172 
Enlargement  of  liver,  163 
Enteritis  in  gastric  cancer,  106 
Eosinophiles  in  gastric  cancer,  333 
Epigastric  pain,  124 

in  duodenal  ulcer,  388 

tenderness  in  duodenal  ulcer,  389 

tumor  in  gastric  cancer  in  young, 
378 
Ereptases,      specific,      Abderhalden 

method  for  detection  of,  344 
Ereptic  ferment  in  gastric   cancer, 

367 
Eructations,  483 

in  duodenal  ulcer,  388 

in  gastric  cancer  in  young,  378 
En,'sipela3  with  gastric  cancer,  49 
Erj"throcji;es,    influence    of    metas- 
tases on,  322 

quantitative  changes  in,  321 

shape  of,  326 

size  of,  326 
Esophageal   lesions,    gastric    cancer 

and,  differential  diagnosis,  392 


Etiologic  factors  in  gastric  cancer,  354 
Examination  by  fluoroscopic  screen, 
275 
of  abdomen,  166 

of  feces,   256.     See  Feces,  exami- 
nation of. 
of  gastric  function,  193 
by  test-meal,  194 
of   secretory'  function   in   gastric 

cancer,  224 
physical,  significance  of,  365 
Roentgen,  268 
Excision,  complete,  in  gastric  can- 
cer, 418 
of  colon  in  involvement  of  trans- 
verse colon  in  gastric  cancer,  469 
of  pyloric  cancer,  drainage  after, 
454 
end  of  stomach,  441,  446 

care    of    transverse    colon 

in.  448 
treatment  of  stumps  in,  448 
Exploratory  laparotomy,  382 
Extra-esophageal   growths,    circiun- 

scribed,  excision  of,  424 
Extragastric     cancer,     Wolff-Jung- 
hans'  test  in,  252 
disease  association  of  gastric  can- 
cer with,  48 
Extraglandular    structures,    hyper- 
plasia of,  90 
Extrapyloric  cancer.  420 

circumscribed,  excision  of,  424 

Facial  appearance,  161 

Family  incidence  of  gastric  cancer, 

44,  45 
Farmers,  gastric  cancer  in,  31 
Fasting  stomach  extracts,  acidity  of, 
201 
free  hydrochloric  aciditj^  iu, 
degree  of,  202 
method    of    determin- 
ing, 202 
Fasting     stomach     extracts,     total 
acidity  of,  202 
determination  of,  203 
Feces,  bfliverdin  in,  259 
blood  in,  259 
cr^-stals  in.  266 


510 


INDEX 


Feces,    diastase    in,    Wohlgemuth's 
method  of  determining,  261 
examination  of,  256 
chemical,  258 
macroscopic,  256 
microscopic,  263 
method,  264 
ferment  tests  of,  261 
hydrobilirubin  in,  258 
leucocytes  in,  266 
microscopic  findings  in,  265 
protozoa  in,  265 
reaction  of,  258 
red  blood  corpuscles  in,  266 
tryptic  digestion  in,   Gross-Wyn- 
hausen's  method  of  determin- 
ing, 263 
undigested  food  in,  266 
Feldstein  and   WeU's  viscosimeter, 

344 
Ferment  tests  of  feces,  261 
Ferments,  gastric,  tests  for,  227 
Fetor  ex  ore,  161 
Fibiger's  rat  tumors,  84 
Fibrous  gastric  cancer,  52 
Fistulse  in  gastric  cancer,  103 
Fixation  of  stomach  in  gastric  ulcer, 

387 
Flatulence,  485 

Fluoroscopic  examination  in  gastric 
carcinosis,  281 
of  abnormalities  in  gastric  out- 
line, 277 
of  growth  at  cardia,  279 

high  in  lesser  curvature,  279 
in  pars  media,  279 
in  pyloric  region,  280 
on  anterior  wall,  281 
on  posterior  wall,  281 
of  peristalsis,  282 
palpation  in,  282 
screen,  examination  by,  275 
negative  findings,  276 
positive  findings,  276 
Food  desire,  125 

relation  of  abdominal  pain,  364 
remnants  in  gastric  extract,  366 
Foreign  bodies  in  large  bowel,  gas- 
tric   cancer    and,  differential 
diagnosis,  412 


Foreign  bodies  in  stomach,  gastric 
cancer    and,    differential    diag- 
nosis, 412 
Formol  index,  229 
Free  hydrochloric  acidity  of  fasting 
stomach       extracts, 
degree  of,  202 
method    of    determin- 
ing, 202 
Frequency  of  gastric  cancer,  17 

retention,  200 
Freund  and  Kaminer  test,  339 
for  precipitate,  341 
ingredients  of,  339 
second,  341 
technic  of,  341 
Frozen  sections,  examination  of,  for 

malignancy,  187 
Fuld   and  Levison,  edestin  test  of, 

228 
Fundus,  cancer  of,  Roentgenographic 
appearance,  292 

Gall-bladder  disease,  gastric  can- 
cer and,  differential  diagnosis, 
394 
association  of  gastric  ulcer  with, 
384 
Gall-stones,  149 
Gall-tract,  cancer  of,  gastric  cancer 

and,  differential  diagnosis,  394 
Gastrectomy,  complete,  456 
operative  technique  for,  457 
partial,     gastro-enterostomy    fol- 
lowing, 459 
total,  prognosis  after,  442 
Gastric  acidity  in  gastric  cancer  in 
young,  379 
ulcer,  386 
low,    Wolff-Junghans'    test    in, 

254 
relation     of     glycyltryptophan 
test  to,  239 
of  tryptophan  test  to,  240 
cancer,  17,  28 

abscess  of  pancreas  and,  differen- 
tial diagnosis,  401 
achylia  gastrica  and  differential 
diagnosis,  403 
associated  with,  47 


INDEX 


511 


Gastric  cancer,   acidity  of  stomacti 

after  operation  for,  466 

actinomycosis  associated  vrith., 
48  ' 
in  etiology  of,  27,  354 

alcoliol  in  etiology  of,  37 

ascites  in,  105 

Asiatic  cholera  with,  49 

association   with   other   gastric 
disease,  46 

asthma  with,  50 

bacteria  in,  43 

Beck's  operation  in,  421 

benign  t}"pe,  51 

blood  in,  319 
changes,  321 

Blight's  disease  with,  50 

cancer    of    gall-tract    and,    dif- 
ferential diagnosis,  394 

carcinomatous  type,  52 

care  of  oral  ca^'ity  in,  474 
of  teeth  in,  474 

causes,  possible,  17-45 

cholecystitis  with,  48 

choleHthiasis  with,  48 

chronic   constipation   and,    dif- 
ferential diagnosis,  414 

cirrhosis  of  Liver  with,  50 

of  stomach  and,   differential 
diagnosis,  411 

classification  of,  51 

clinical  consideration,  354 
differentiation    from     gastric 
cancer,  358 

clinically  carcinomatous  period 
of,  130 
developing  in  patients  with 
years  of  antecedent  dys- 
pepsia of  peptic  ulcer  t%T)e, 
122 

colloid  type,  58 

complete  excision,  418 

conjugal  state  in  etiology"  of,  35 

constitutional  diseases  with,  50 
fatilts   and,  differential  diag- 
nosis, 416 

cyst  of  pancreas  and,  differential 
diagnosis,  401 

decayed  teeth  in,  161 

definition,  17 


Gastric  cancer,  diabetes  with,  50 

diagnostic  errors  in,  24 

diet  in,  477 
after  operation  for,  466,  467 
in  etiology  of,  35 

diphtheria  with,  49 

disease  of  pancreas  and,  dift'er- 
ential  diagnosis,  397 

duodenal  ulcer  and,  differential 
diagnosis,  391 

early  diagnosis  of,  112 

Roentgen      examination     in, 
273 

eczema  with,  50 

edema  in,  162 

enteritis  in,  106 

ereptic  ferment  in,  367 

erA'sipelas  with,  49 

esophageal  lesions   and,    differ- 
ential diagnosis,  392 

etiologic  factors  in,  354 

etiology,  possible,  17-45 

excision  of  colon  in  involvement 
of  transverse  colon  in,  469 

experimental  production  in  ani- 
mals, 84 

facial  appearance  in,  161 

family  incidence  of,  44,  45 

fetor  ex  ore  in,  161 

fibrous  type,  52 

fistulse  in,  103 

foreign   bodies   in  large   bowel 
and,  dift'erential  diagnosis, 
412 
in  stomach  and,  differential 
diagnosis,  412 

gall-bladder    disease    and,    dif- 
ferential diagnosis,  394 

gastric   granuloma  and,   differ- 
ential diagnosis,  411 
s^'philis  associated  with,  47 
ulcer  and,  differential  diagno- 
sis, 391 

gelatinous  type,  58 

general  comphcations,  100 

distribution,  17 
frequency,  17 

glycyltrj-ptophan  test  in,  238 

gonorrhea  with,  49 

gout  with,  50 


512 


INDEX 


Gastric     cancer,     gross     deviations 
from  normal  in,  52 
habits  in  etiology  of,  38 
hemorrhage  in,  101 
heredity  in  etiology  of,  43,  474 
histologic  deviations  from  nor- 
mal in,  58 
hygiene  in  etiology  of,  41 
in  cases  operated  for  clinically 
benign  gastric  ulcer  in  whom 
cancer    was    microscopically 
diagnosed,  113-122 
in  farmers,  31 
in  Jews,  30 
in  negroes,  28 

in  patients  in  whom  malignancy 
followed  periods  of  gastric 
disturbance     of     irregular 
clinical  type,  149-153 
who    presented    few    clinical 
evidences  of  malignant  pro- 
cess   primary    in    stomach 
waU,  153-157 
who  prior  to  onset  of  malig- 
nant   disease    had    perfect 
gastric  health,  134-148 
in  young,  373 

abdominal  tenderness  in,  378 
appetite  in,  376 
blood  in,  379 

character  of  neoplasms  in,  380 
clinical  data  in,  376 
constipation  in,  376 
duration     of     gastric     com- 
plaints in,  374 
epigastric  tumor  in,  378 
eructations  in,  378 
gastric  acidity  in,  379 

emptying  power  in,  379 
incidence  of,  373 
laboratory  data  in,  379 
laparotomy  findings  in,  380 
location  of  malignant  process 

m,  380 
microscopic    examination    of 
unfiltered   gastric   extracts 
in,  380 
"occult"  blood  in,  380 
operative  procedures  in,  380 
outcome  of,  380 


Gastric    cancer,    in  young,   pyrosis 
in,  378 

stools  in,  379 

test-meals  in,  379 

types  of  histories  in,  374 

vomiting  in,  378 

weight  loss  in,  376 
incidence  of  ascites  in,  409 
increase  in,  26 

indications   for   medical   treat- 
ment in,  474 
infectious  diseases  with,  48 
involvement  of  transverse  colon 

in,  443 
jaundice  in,  106 
lack  of  progress  in  study  of,  353 
la  grippe  with,  49 
liver  metastases  in,  105 
location  of,  97,  368 

tables  of,  99 
lung  metastases  in,  105 
malaria  with,  49 
malignant    hour-glass    contrac- 
tion in,  101 

peritonitis    and,     differential 
diagnosis,  405 

type,  51 
management  of  symptoms  in, 

482 
measles  with,  49 
medullary  type,  53 
morbid  anatomy  of,  51 
mortality,  general  increase,  20 

table  of,  18-23 
mucoid  type,  58 
mucous  surfaces  in,  161 
mumps  with,  49 
nationality  in  etiology  of,  28 
nephritis  in,  106 
nervous  compUcations  in,  106 
non-surgical  treatment  of,  472 
nutrition  in  etiology  of,  35 
obstruction  at  cardia  in,  100 
occupation  in  etiology  of,  31 
parasitic  infections  with,  49 
pathologic  differentiation  from 

gastric  ulcer,  358 
pathology  of,  370 
perforation  in,  101 

perigastric  abscess  in,  102 


INDEX 


513 


Gastric     cancer,     pneumonia     after 
operation  for,  463 
precarcinomatous  period  in,  123, 

149 
preparation  for  operation  in,  419 
previous  disorders  of  digestion 

in,  355 
proctoclysis  after  operation  in, 

465 
prognosis  after  operation  in,  442 
prophylaxis  in,  472 
proteid  diet  in  etiology  of,  37 
protozoal  infection  with,  50 
protozoic    infections    of    bowel 
and,     differential     diagnosis, 
414 
pyloric  obstruction  in,  100 
quinsy  with,  49 
rate  of  growth,  95 
age  factor  in,  96 
influence  of  body  nutrition 
on,  96 
of  location  in,  97 
ratio  of  occurrence,  22 
raw  food  in  etiology  of,  33 
rectal  feeding  in,  481 
relation  to  gastric  ulcer,  46 
sarcoma  of  stomach  and,   dif- 
ferential diagnosis,  412 
sarcomatous  type,  52 
scarlet  fever  with,  49 
secondary  to  extragastric  malig- 
nant process,  157 
to   malignancy   in   other   or- 
gans, 409 
Senn's  operation  for,  423 
seven  signs  of  inoperability  of, 

186 
sex  in  etiology  of,  26 
significance  of  gastric  ulcer  with 
respect  to,  350 
of  history  in,  354 
smallpox  with,  49 
Smithies'  percussion  sign  in,  188 
social  status  in  etiology  of,  34 
surgical  treatment  of,  417 
symptomatology,  110 
symptom-complexes  of,  112 
syphilis  of  stomach  and,  differ- 
ential diagnosis,  409 
33 


Gastric  cancer,  thrombosis  in,  106 
tobacco  habit  in,  etiology  of,  38 
toilet  of  stomach  in,  476 
tonsillitis  with,  49 
traumatism  in  etiology  of,  39,  40 
treatment    of,    by   autolysates, 
496 
by  chemotherapy,  499 
by  Coley's  toxins,  496 
by  mesothorium,  495 
by  radio-active  water,  495 
by  radium,  495 
by  Roentgen  rays,  493 
by  serotherapy,  496 
by  vaccines,  496 
by    Vaughan's    split-proteid 
vaccine,  497 
tryptophan  test  in,  237 
tuberculosis    of    stomach    and, 

differential  diagnosis,  410 
tumors  of  abdominal  wall  and, 
differential  diagnosis,  416 
of    kidney    and,    differential 

diagnosis,  402 
large  intestine  and,  differen- 
tial diagnosis,  402 
of  liver  and,  differential  diag- 
nosis, 396 
of  omentum  and,  differential 

diagnosis,  402 
of  retroperitoneal  tissues  and, 

differential  diagnosis,  402 
of   small  intestine   and,    dif- 
ferential diagnosis,  403 
types  of,  370 
typhoid  fever  with,  49 
ulcerating  type,  54 
variation  in  pathologic  opinion 

as  to  life  history  of,  352 
venereal  disease  in  etiology  of, 

39 
with    malignancy    primary    in 

other  organs,  48 
with  pleurisy,  49 
with  pneumonia,  49 
with  rheumatism,  49 
with  tuberculosis,  47,  48 
with  yellow  fever,  49 
carcinosis,    fluoroscopic   examina- 
tion in,  281 


514 


INDEX 


Gastric  disease,  association  with  gas- 
tric ulcer,  46 
emptying  power  in  gastric  cancer 
in  young,  379 
investigation  of,  194 
normal,  time  limit  for,  196 
physiologic  method  of  estimat- 
ing, 195 
extract,  acidity  of,  366 

blood    in    relation    of    Wolff- 

Junghans'  test  to,  255 
food  remnants  in,  366 
lactic  acid  in,  366 
microscopic  examination  of,  367 
occidt  blood  in,  367 
Oppler-Boas  bacilU  in,  367 
unfiltered  microscopic  examina- 
tion of,  380 
ferments,  tests  for,  227 
function,  examination  of,  193 

by  test-meal,  193 
hemorrhage,  treatment  of  anemia 

after,  493 
inflation,  effect  of,  on  abdominal 

tumor,  182 
lavage  before  abdominal  examina- 
tion, 167 
lumen,  patent,  diet  in,  479 
mucosa,  hyperplasia  of  elements 
of,  86 
retrograde  changes  in,  93 
neoplasms,  classification  of,  51 
location  of,  97 
rate  of  growth,  95 
outline,  abnormalities  in,   fluoro- 
scopic examination  of,  277 
residue  in  gastric  ulcer,  387 
retention  extracts,  acid  salts  in,  203 
acidity  in,  225 
amdunt  of,  225 
bacteria  in,  211 
bile  coloring  in,  200 
chymification  of,  201 
color  of,  200 
combined  acidity,  226 
degree   of   combined   acidity 
of,  203 
of  total  acidity  of,  203 
examination     of      unstained 
preparations,  210 


Gastric     retention     extracts,     free 
hydrochloric  acid  in,  225 
Gluzinski's  method  of  deter- 
mining, 226 
lactic  acid  in,  226 

method     of    determina- 
tion of,  204 
macroscopic    study    of,    200, 

225 
microscopic   examination   of, 
206,  226 
method  of,  207 
significance  of,  210 
mucus  in,  201 
"occult"  blood  in,  204,  226 
benzidin  test  for,  205 
instances  of,  206 
method  of  determining, 
205 
odor  of,  201,  225 
Oppler-Boas  bacillus  in,  211 
staining,     by     colored     agar 

method,  208 
traumatic  blood  in,  200 
frequency  of,  200 
syphilis    associated   with    gastric 

cancer,  47 
ulcer,  384 

actinomycosis  associated  with, 

47 
alterations  in  gastric  peristalsis 

in,  387 
area  of  tenderness  in,  387 
association  with  disease  of  ap- 
pendix, 384 
of  gall-bladder,  384 
clinical  differentiation  from  gas- 
tric cancer,  358 
dietetic  irregularities  in,  384 
epigastric  distress  in,  384 
facts  determined  from  history 
of,  384 
obtained  by  examination  in, 

385 
secured  by  laboratory  exami- 
nation in,  385 
fixation  of  stomach  in,  387 
food  relief  of  distress  in,  384 
gastric  cancer  and,  differential 
diagnosis,  391 


INDEX 


515 


Gastric   ulcer,   gastric    cancer,  and, 
residue  in,  387 
geographic    variation    in    inci- 
dence of,  351 
glycyltryptophan  test  in,  238 
hemorrhage  in,  385 
hour-glass  stomach  in,  387 
hyperplasia  in,  86 
in  young,   abdominal   pain   in, 

377 
malignant  ulcer  in,  361 
microscopic  examination  in,  386 
pathologic  differentiation  from 

gastric  cancer,  358 
periodicity  of  complaint  in,  384 
recurring    acute    infections    in, 

384 
relation  to  gastric  cancer,  46 
Roentgen-ray  findings  in,  387 
significance  of,  with  respect  to 

gastric  cancer,  350 
simple,  Wolff-Junghans'  test  in, 

253 
stools  in,  386 
symptomatology,  when  disease 

is  well  established,  146 
symptom-complexes  of,  356 
test-meal  findings  in,  385 
tryptophan  test  in,  238 
variation    in    accepted    clinical 
complex  of,  353 
in  pathologic   opinion  as  to 
life  history  of,  352 
vomiting  in,  385 
Gastro-enterostomy,  anterior,  430 
following  partial  gastrectomy,  459 

technique  of,  460 
for  carcinoma  of  pylorus,  427 
lavage  after,  439 
opening,  location  of,  428 
posterior,  428 
Gastrojejunostomy,  431 
anterior,  429 
posterior,  431,  432 
Gastroscope,  Sussmann,  190 
Gastroscopy,  189 
Gastrostomy,  Witzel's  technique  of, 

422 
Gelatinous  gastric  cancer,  58 
General  appearance  of  patient,  160 


Geographic  variation  in  incidence  of 

gastric  ulcer,  351 
Gland  cells,  abnormal  proliferation 

of,  79 
Gluzinski's  method  of  determining 
acidity    of   gastric    retention   ex- 
tracts, 226 
Glycyltryptophan  test,  230,  367 
effect  of  bile  on,  242 
of  blood  on,  243 
of  chyle  on,  242 
in  duodenal  ulcer,  238 
in  gastric  cancer,  238 
organic  acid  in,  241 
relation  of,  to  gastric  acidity, 

239 
results,  23^237 
Smithies'  modification  of,  232 
summary,  244 
Gonorrhea  with  gastric  cancer,  49 
Gout  with  gastric  cancer,  50 
Granuloma,  gastric  cancer  and,  dif- 
ferential diagnosis,  411 
Green  diarrhea,  259 
Gross- Wynhausen's  method  of  deter- 
mining tryptic  digestion  in  feces, 
263 
Growth  of  gastric  neoplasms,  rate  of, 

95 
Gum  chewing  after  operation,  465 


Habits  in  etiology  of  gastric  cancer, 

38 
Hematemesis,  364 

in  duodenal  ulcer,  388 
Hemoglobin  in  duodenal  vilcer,  389 

influence  of  metastasis  on,  325 

quantitative  changes  in,  324 
Hemolytic  reaction,  334,  367 

technique  of,  335 
Hemorrhage,  101,  115,  147,  149,  364, 
486 

treatment  of  anemia  after,  493 

in  duodenal  ulcer,  388 

in  gastric  ulcer,  385 

"occult,"  147 

treatment  by  coagulose,  486 
Heredity  in  etiology  of  gastric  can- 
cer, 43,  474 


516 


INDEX 


Histologic   deviations   from   normal 
in  gastric  cancer,  58 
type,  influence  of,  on  demonstra- 
tion of  mobility  of  abdominal 
tumor,  180 
History,  precancerous,  355 

significance  of,  in  gastric  cancer, 
354 
Hot  bath  before  abdominal  palpa- 
tion, 173 
Hour-glass   contraction,   malignant, 
in  gastric  cancer,  101 
in  gastric  ulcer,  387 
Hydrobilirubin  in  feces,  258 
Hydrochloric   acid,   free,   in  gastric 

retention  extracts,  225 
Hygiene  in  etiology  of  gastric  can- 
cer, 41 
Hyperplasia  in  gastric  ulcer,  86 
of  elements  of  gastric  mucosa,  86 
of  extraglandular  structures,  90 

Incidence     of    gastric     cancer     in 

young,  373 
Index,  formol,  229 

peptic,  228 
Indigestion,  124 
Indurated  duodenal  ulcer,  360 
Infectious    diseases,    gastric    cancer 

with,  48 
Ingredients  of  test-meal,  195 
Inguinal  nodes,  involvement  of,  184 
Inspection  of  abdomen,  169 

of  patient,  160 
Investigation    of    gastric    emptying 

power,  194 
Involvement  of  Blumer's  shelf,  184 

of  inguinal  nodes,  184 

of  liver,  186 

of  lymph-glands,  184 

of  pyloric  lymph-glands,  186 

of  supraclavicular  glands,  185 

Jaundice,  149 

in  gastric  cancer,  106 
Jews,  gastric  cancer  in,  30 
Junghans-Wolff     test    for      soluble 

albumin,  245,  368 

Kaminer  and  Freund  test,  339 


Kidney,    tumors   of,    gastric  cancer 
and,  differential  diagnosis,  402 

Laboratory  data  in  gastric  cancer 
in  young,  379 
examination,  facts  secured  by,  in 
gastric  ulcer,  385 
Lactic  acid  in  gastric  retention  ex- 
tracts, 226,  366 
method     of     determina- 
tion, 204 
La  grippe  with  gastric  cancer,  49 
Laparotomy,  exploratory,  382 

findings     in     gastric     cancer     in 

young,  380 
in  chronic  dyspepsia,  472 
Large    intestine,     tumors    of,     and 
gastric  cancer,  differential  diagno- 
sis, 402 
Lavage  after  posterior  gastro-enter- 
ostomy,  439 
best  time  for,  477 
in    post-operative    dilatation    of 

stomach,  465 
tube,  196,  197.     See  also  Stomach 
tube. 
Leucocyte  count,  maximum,  329 

minimum,  329 
Leucocytes,    basophile,     in    gastric 
cancer,  332 
changes  in,  quantitative,  327 
in  feces,  266 

polynuclear,  in  gastric  cancer,  332 
qualitative  variation  in,  332 
transitional,  in  gastric  cancer,  332 
Leucocytosis,  329 

digestion,  332 
Levison  and  Fuld,  edestin  test  of, 

228 
Liver,  enlargement  of,  163 
involvement  of,  186 
metastases  in  gastric  cancer,  105 
tumors  of,  gastric  cancer  and,  dif- 
ferential diagnosis,  396 
Location  of  gastric  cancer,  97,  368 

in  young,  380 
Loss  of  weight,  150,  154,  163 
Lungs,  metastases  to,  in  gastric  can- 
cer, 105 
Lymph-glands,  involvement  of,  184 


INDEX 


517 


Lymphocj-tes,  large,  in  gastric  can- 
cer, 332 
small,  in  gastric  cancer,  332 

]Macroscopic   examination   of    cul- 
tures of  Oppler-Boas  bacillus, 
215,  222,  223 
of  feces,  256 

of    gastric    retention    extracts, 
200,  225 
"Magenweg,"  279 
]Malaria  with  gastric  cancer,  49 
Malignanc}^  primarj^  in  other  organs, 

gastric  cancer  with,  48 
Malignant  and  benign  groA;rths,  as- 
sociation of,  371 
gastric  cancer,  51 
period,  duration  of,  132 
ulcer  in  gastric  ulcer,  361 
Management  of  sjTnptoms  in  gas- 
tric cancer,  482 
Measles  with  gastric  cancer,  49 
Medullary  gastric  cancer,  53 
Melena,  364 

in  duodenal  ulcer,  388 
Mental    attitude    factor    in   weight 

loss,  166 
Mesothorium,  treatment  of  gastric 

cancer  by,  495 
Metagastric  alimentation,  478 
Metastasis,  external  e^ddence  of,  162 
influence  on  er\i;hroc}'tes,  322 

on  hemoglobin,  325 
to  peritoneum,  163 
Meyer  and  Bergmann's  antitryptic 

reaction,  342 
Meyer,   Willy,    air-pressure   cabinet 

of,  421 
Microscopic  examination  in  gastric 
ulcer,  386 
of  cidtuxes  of  Oppler-Boas  bacil- 
lus, 222,  223 
of  feces,  263 

method  of,  264 
of    gastric    retention    extracts, 
206,  226 
method  of,  207 
significance  of,  210 
of  Oppler-Boas  bacillus,  215 
findings  in  feces,  265 


:Milk,  cancer,  246 

Miostagmin  reaction,  AscoH's,  348 

Mobility  of  abdominal  tumor,  179 

]Mode  of  onset,  in  gastric  cancer,  113, 
136 

Morbid  anatomj',  of  gastric  cancer, 
51 

Mortality,  tables  of,  in  gastric  can- 
cer, 18-23 

Motor-meal  tube,  Smithies',  196,  197 

-Mucoid  gastric  cancer,  58 

Mucous  membranes,  appearance  of, 
319 
surfaces,.  161 

Mucus  in  gastric  retention  extracts, 
201 

Miunps  with  gastric  cancer,  49 

Murphy  drip  method  of  rectal  feed- 
ing, 481 

]vIyeloc}"tes  in  gastric  cancer,  332 

Xatigxalitt  in  etiology  of  gastric 
cancer,  28 

Negative  test  for  "occult"  blood,  261 

Xegroes,  gastric  cancer  in,  28 

Xelaton  tumor,  174 

Xephritis  in  gastric  cancer,  106 
Wolff-Junghans'  test  in,  254 

Xers^ous    comphcations    in    gastric 
■  cancer,  106 
signs,  163 

Non-pjdoric  cancers,  surgical  treat- 
ment of,  420 

Xon-surgical    treatment    of    gastric 
cancer,  472 

Xutrition,  115 

in  etiologj'  of  gastric  cancer,  35 

"Occult"  blood,  clinical  interpreta- 
tion of  tests  for,  260 
in  gastric  cancer  in  young,  380 
retention  extracts,  204,  226, 
367 
benzidin  test  for,  205 
instances  of,  206 
method  of  determining, 
205 
negative  test  for,  261 
hemorrhage,  147 


518 


INDEX 


Occupation    in    etiology    of    gastric 

cancer,  31 
Odor  of  gastric  retention  extracts, 

201,  225 
Omentum,  tumors  of,  gastric  cancer 

and,  differential  diagnosis,  402 
Operation,  chewing  of  gum  after,  465 
in  gastric  cancer,  preparation  for, 
419 
Operative    technique    for    gastrec- 
tomy, 457 
Oppler-Boas  bacillus,  artificial  cult- 
ure of,  214 
characteristics  of,  212 
cultures  in  beef  bouillon,  216 

after   forty-eight    hours, 

220 
after  seventy- two  hours, 
221 
macroscopic   examination, 

222,  223 
microscopic  examination,  222, 
223 
frequency  of  occurrence,  224 
in  gastric  extract,  367 

retention  extracts,  211,  212 
macroscopic  examination,  215 
microscopic  examination,  215 
staining  properties  of,  213 
Oral  cavity,  care  of,  in  gastric  can- 
cer, 474 
condition,  bad,  weight  loss  from, 
165 
Organic    acid    in    glycyltryptophan 
test,  241 
in  tryptophan  test,  241 

Pain,  485 

abdominal,  132,  149 
food  relation  of,  364 
in  gastric  cancer  in  young,  377 

epigastric,  124 

time  in  duodenal  ulcer,  388 

types  of,  116,  364 
Palpation,  abdominal,  172 

in  fluoroscopy,  282 
Pancreas,  disease  of,  gastric  cancer 

and,  differential  diagnosis,  397 
Parasitic     infections     with     gastric 

cancer,  49 


Pars    media,   fluoroscopic   examina- 
tion of  growth  in,  279 
growth    in,     Roentgenographic 
appearance  of,  292 
Partial    gastrectomy,    gastro-enter- 

ostomy  following,  459 
Passage  of  stomach  tube,  technique 

of,  199 
Pathology  of  gastric  cancer,  370 
Patient,  general  appearance  of,  160 
after  establishment  of  malig- 
nancy, 161 

inspection  of,  160 

preparation  of,  for  operation,  419 
Pepsin,  tests  for,  227 
Peptic  index,  228 
Percussion,  187 
Percy  and  Cook's  method  of  blood 

transfusion,  486 
Perforation  in  gastric  cancer,  101 
Perigastric    abscess    in    perforating 

gastric  cancer,  case,  102 
Periodicity  of  symptoms,  363 
Peristalsis,  fluoroscopic  examination 
of,  282 

alterations    of,    in    gastric   ulcer, 
387 

visible,  in  abdominal  inspection, 
170 
Peritoneal  cavity,  presence  of  free 

fluid  in,  185 
Peritoneum,  metastasis  to,  163 
Peritonitis,  malignant,  gastric  can- 
cer   and,     differential    diagnosis, 

405 
Phantom  tumor,  171 
Physical  abnormalities,  160 

examination,  signiflcance  of,  365 
Physiologic    method    of    estimating 

gastric  emptying  power,  195 
Plethora  in  duodenal  ulcer,  389 
Pleurisy,  gastric  cancer  with,  49 
Pneumonia  after  operation  for  gas- 
tric cancer,  463 

gastric  cancer  with,  49 
Poikilocytosis,  327 
Polynuclear    leucocytes    in    gastric 

cancer,  332 
Poor-appetite     habit,     weight    loss 

from,  166 


INDEX 


519 


Position  of  abdominal  tumor,  176 

relation  to   part  of  stomach 
involved,  177 
of  patient  for  abdominal  examina- 
tion, 168 
Posterior-gastro-enterostomy,  428 
after-treatment  of,  440 
diet  after,  441 
gastrojejunostomy,  431,  432 
wall,  fluoroscopic  examination  of 
growth  on,  281 
Roentgenographic     appearance 
of  growth  in,  292 
Post-operative   dilatation   of   stom- 
ach, 463,  464 
lavage  for,  465 
treatment,  463 
Precancerous  history,  355 
Precarcinomatous  period,  123,  149 
Preparation  for  operation  in  gastric 
cancer,  419 
of  patient  for  abdominal  examina- 
tion, 167 
for  operation,  419 
for  Wolff-Junghans'  test,  247 
of  stomach  for  operation,  419 
Proctoclysis  after  operation  in  gas- 
tric cancer,  465 
Prognosis  after  operation  in  gastric 
cancer,  442 
after  total  gastrectomy,  442 
Prophylaxis  in  gastric  cancer,  472 
Proteid   diet   in  etiology  of  gastric 

cancer,  37 
Protozoa  in  feces,  265 
Protozoal     infection     with     gastric 
cancer,  50 
of   bowel,   gastric   cancer   and, 
differential  diagnosis,  414 
Pyloric  cancer,  drainage  after  exci- 
sion of,  454 
end  of  stomach,  excision  of,  441, 
446 
Roentgenographic       appear- 
ance of  growth  at,  303 
lymph-glands,  involvement  of,  186 
obstruction  in  gastric  cancer,  100 
region,    fluoroscopic    examination 

of  growth  in,  280 
stenosis,  diet  in,  478 


Pylorus,  carcinoma  of,  426 

Pyorrhea  alveolaris,  161 

Pyrosis,  483 

in  duodenal  ulcer,  388 

in  gastric  cancer  in  young,  378 

Qualitative  variation  in  leucocytes, 

332 
Quantitative    changes    in    erythro- 
cytes, 321 
in  hemoglobin,  324 
Quinsy  with  gastric  cancer,  49 

Race  in  etiology  of  gastric  cancer,  28 

Radio-active  water,  treatment  of 
gastric  cancer  by,  495 

Radium  in  treatment  of  gastric  can- 
cer, 495 

Ransohoff's  anaphylaxis  test,  348 

Rat  tumors,  Fibiger's,  84 

Raw  food  in  etiology  of  gastric  can- 
cer, 33 

Reaction,    antitryptic,    Bergmann 
and  Meyer's,  342 
Ascoli's  miostagmin,  348 
glycyltryptophan,  231,  367 
hemolytic,  334,  367 
technique  of,  335 
of  feces,  258 
skin,  337 
tryptophan,  231 

Reagent,  Wolff's,  248 

Rectal    feeding    by    Murphy    drip 
method,  481 
in  gastric  cancer,  481 

Red  blood  corpuscles  in  feces,  266 

References  to  Hterature,  50,  108, 
266,  349,  371,  381,  416,  499 

Registration  of  cancer  cases,  474 

Rennin,  tests  for,  227 

Respiratory  movements,  effect  of, 
on  mobility  of  abdominal  tumor, 
183 

Retrograde  changes  in  gastric  mu- 
cosa, 93 

Retroperitoneal  tissues,  tumors  of, 
gastric  cancer  and,  differential 
diagnosis,  402 

Rheumatism,  gastric  cancer  with, 
49 


520 


INDEX 


"Ring    cancer,"     Roentgenographic 

appearance  of,  303 
Roentgen  diagnosis  in  earlj-  gastric 
cancer,  273 
examination,  268 

class  of  cases  for,  268 
information  derived  from,  287 
methods  of,  27-i 
rays,  treatment  of  gastric  cancer 
by,  493 
indications  for,  494 
Roentgenographic     appearance     of 
body  of  stomach,  292 
of  cancer  of  fundus,  292 
of  growth  in  anterior  wall,  292 
in  pars  media,  292 
in  posterior  wall,  292 
of  ring  cancer,  303 
plates,  examination  by,  283 
mode  of  procedure,  284 
Roentgen-ray    findings    in    gastric 
ulcer,  387 

Sarcoma,  gastric,  52 

gastric  cancer  and,  differential 
diagnosis,  412 

Scarlet  fever  with  gastric  cancer,  49 

Scirrhus,  52 

Sclera,  appearance  of,  319 

Secretory  function  of  stomach,  ex- 
amination of,  224 

Senn's  operation  for  gastric  cancer, 
423 

Serotherapy  in  gastric  cancer,  496 

Seven  signs  of  inoperability  of  gas- 
tric cancer,  186 

Sex  in  duodenal  ulcer,  387 

in  etiologj!-  of  gastric  cancer,  26, 
354 

Shadows,  blood,  327 

Shape  of  erythrocj^tes,  326 

Significance    of    clinical    symptoms, 
363 
of  physical  examination,  365 
of  test-meal  findings,  366 

Size  of  abdominal  tumor,  178 
of  erj^hrocj^tes,  326 

Skin,  appearance  of,  319 
in  abdominal  palpation,  173 
reaction,  337 


Small  intestine,   tumors   of,   gastric 
cancer  and,  differential  diagnosis, 
403 
Smallpox  with  gastric  cancer,  49 
Smithies'      colored     agar     staining 
method,  208 
method  of  examination  of  gastric 

retention  extracts,  210 
modification  of  glycyltryptophan 
test,  232 
of  tryptophan  test,  233 
motor-meal  and  lavage  tube,  196, 

197 
percussion  sign  in  cancer  of  fun- 
dus of  stomach,  188 
Social  status  in  etiology  of  gastric 

cancer,  34 
Soluble    albumin,    Wolff-Junghans' 

test  for,  245,  368 
Special  tests,  367 
Splenic  enlargement,  gastric  cancer 

and,  differential  diagnosis,  402 
Split-proteid  vaccine,  Vaughan's,  for 

treatment  of  gastric  cancer,  497 
Staining  of  gastric  retention  extracts, 

by  colored  agar  method,  208 
Stomach,    cancer  of,    17.     See   also 
Gastric  cancer. 
diet  in  growths  in  body  of,  477 
dilated,  in  duodenal  ulcer,  389 
examination    of    secretory    func- 
tion of,  224 
excision  of  pyloric  end  of,  446 
post-operative  dilatation  of,  463, 

464 
preparation  of,  for  operation,  419 
testing  emptying  power  of,  275 
toilet  of,  in  gastric  cancer,  476 
tube.  Smithies',  196,  197 
advantages  of,  198 
description  of,  197 
faiilts  of  ordinarj',  197 
technique  for  passage  of,  199 
Stools,    examination    of,    256.     See 
also  Feces,  examination  of. 
in  gastric  cancer  in  young,  379 
ulcer,  386 
Strength  of  patients,  115 
Supraclavicular  glands,  involvement 
of,  185 


INDEX 


521 


Surgical  considerations,  368 

treatment  of  gastric  cancer,  417 
of  non-pyloric  cancers,  420 
Sussmann's  gastroscope,  190 
Symptomatology'  of  gastric  cancer, 

110 
Symptom-complexes  of  gastric  can- 
cer, 112 
of  gastric  ulcer,  356 
Symptoms,  clinical,  significance,  363 

periodicity  of,  363 
SypMlis,     gastric,     Wolff-Junghans' 
test  in,  252 
gastric  cancer  and,  differential 
diagnosis,  409 

Technique  of  blood  transfusion,  489 

of    gastro-enterostomy    following 

partial  gastrectomy,  460 

Teeth,  care  of,  in  gastric  cancer,  474 

decayed,  161 

extraction   of,    contracting    gums 

after,  475 
in  etiology  of  gastric  cancer,  42 
Temperature,  147 

Tenderness,    abdominal,    in   gastric 
cancer  in  j^oung,  378 
area  of,  in  gastric  ulcer,  387 
of  palpable  abdominal  tumors,  178 
Test,  edestin  of  Fuld  and  Levison, 
228 
glycyltryptophan,  230,  244 
results,  234-237 
Smithies'  modification,  232 
Kaminer  and  Freund,  339 
Ransohoff's  anaphjdaxis,  348 
tr3rptophan,  231 
results,  23-t-237 
Smithies'  modification,  233 
summary,  244 
typical,  234 
Test-meal    examination    of    gastric 
function,  193 
findings,  117 

comparison     of,     with     Wolff- 
Junghans'  test,  251 
in  gastric  ulcer,  385 
significance  of,  366 
ingredients  of,  195 
in  gastric  cancer  in  young,  379 
Tests,  special,  367 


Thrombosis  in  gastric  cancer,  106 
Tobacco  habit  in  etiology  of  gastric 

cancer,  38 
Tonsillitis  with  gastric  cancer,  49 
Total  acidity,  degree  of,  in  gastric 
retention  extracts,  203 
of  fasting  stomach  contents,  202 
determination  of,  203 
Transfusion    of    blood,    Percy    and 

Cook's  method,  486 
Transitional    leucocj'tes    in    gastric 

cancer,  332 
Transverse   colon,  care  of,  in  exci- 
sion of  pj'loric  end  of  stom- 
ach, 448 
involvement  of,  in  gastric  can- 
cer, 443 
excision  of  colon  in,  469 
Traumatism  in  etiology  of  gastric 

cancer,  39,  40 
Treatment  of  anemia  after    gastric 
hemorrhage,  493 
of  gastric  cancer  by  autolysates, 
496 
by  chemotherap}',  499 
by  Coley's  toxins,  496 
by  mesothorium,  495 
by  radio-active  water,  495 
by  radium,  495 
by  Roentgen  rays,  493 
by  vaccines,  496 
medical,  indications  for,  474 
non-surgical,  472 
post-operative,  463 
surgical,  417 
Trj^ptic   digestion   in  feces,    Gross- 
Wynhausen's  method  of  determin- 
ing, 263 
Tryptophan  test,  231 
effect  of  bile  on,  242 
of  blood  on,  243 
on  chyle,  242 
in  duodenal  ulcer,  238 
in  gastric  cancer,  237 

ulcer,  238 
organic  acid  in,  241 
relation  of,  to  gastric  acidity, 

240 
results,  234-237 
Smithies'  modification,  233 
summarj^,  244 


522 


INDEX 


Tryptophan  test,  typical,  234 
Tube  for  blood  transfusion,  487 

for  gastric  lavage,  Smithies',  196, 
197 
Tuberculosis  associated  with  gastric 
cancer,  47,  48 

of  stomach,   gastric   cancer   and, 
differential  diagnosis,  410 
Tumor,  abdominal,  175 

N^laton,  174 

phantom,  171 
Tumors  of  liver,  gastric  cancer  and, 

differential  diagnosis,  396 
Two-stage  operation  for  carcinoma 

of  pylorus,  427 
Types  of  gastric  cancer,  370 

of  pain,  364 
Typhoid  fever  with  gastric  cancer,  49 

Ulcer,    duodenal,    387.     See    also 

Duodenal  ulcer. 
Ulcerating  gastric  cancer,  54 
Ulcus  carcinomatosum,  54,  94,  361 

Wolff-Junghans'  test  in,  250 
Uncolored    preparations    of    gastric 

retention    extracts,     examination 

of,  by  Smithies'  method,  210 
Uncooked  vegetables,  danger  from, 

480 
Undigested  food  in  feces,  266 
Urine,  148 

Vaccine  treatment  of  gastric  can- 
cer, 496 
Vaughan's  split-proteid  vaccine  for 

treatment  of  gastric  cancer,  497 
Venereal  disease  in  etiology  of  gas- 
tric cancer,  39 
Viscosimeter,  Weil  and  Feldstein's, 

344 
Vomiting,  in  duodenal  ulcer,  388 
in    gastric  cancer,    115,  125,  133, 
149,  365,  482 
in  young,  378 
ulcer,  385 
weight  loss  from,  165 

Water-bkash,  114,  149 
in  duodenal  ulcer,  388 
Weight  loss,  125,  148,  150,  154,  163, 
164 
age  factor  in,  165 


Weight  loss,  factor  of  mental  atti- 
tude in,  166 
from  bad  oral  conditions,  165 
from  poor-appetite  habit,  1 66 
from  undereating,  165 
from  vomiting,  165 
in  gastric  cancer  in  young,  376 
Weil   and   Feldstein's  viscosimeter, 

344 
Wilson's   rapid   method   of    cutting 

and  staining  cancer  tissue,  107 
Witzel's  gastrostomy,  technique  of, 

422 
Wohlgemuth's  method  of  determin- 
ing diastase  in  feces,  261 
Wolff-Junghans'  test,  comparison  of 
other  test-meal  findings,  with, 
251 
for  soluble  albumin,  245,  368 
in  achlorhydria,  253 
in  cardiovascular  disease,  254 
in  duodenal  ulcer,  253 
in  extragastric  cancer,  252 
in  gastric  syphilis,  252 
in  low  gastric  acidity,  254 
in  malignant  and  benign  achy- 
lias,  246 
in  nephritis,  254 
in  primary  anemias,  252 
in  simple  achylia  gastrica,  253 

gastric  ulcer,  253 
in  ulcus  carcinomatosum,  250 
interpretation  of,  248 
manifestation  of,  248 
manifestations    of,    relation   to 
location  of  malignant  process, 
250 
mode  of  procedure,  248 
preparation  of  patient  for,  247 
relation  of,  to  presence  of  blood 

in  gastric  extracts,  255 
results  of,  249 
Wolff's  reagent,  248 
Wynhausen-Gross'  method  of  deter- 
mining tryptic  digestion  in  feces, 
263 
X-RAY  examination,  268.     See  also 

Roentgen  examination. 
Yellow  fever  with  gastric  cancer,  49 
Young,  gastric  cancer  in,  373 


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Mallory  and  Wright's 
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McFarland*s  Pathogenic 
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Pathogenic  tSacteria  and  Protozoa.  By  Joseph  McFarland,  M.  D., 
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branches  •  with  over  100  new  and  elaborate  tables  and  many  handsome 
illustrations.  By  W.  A.  Newman  Borland,  M.D.,  Editor  of  "  The 
American  Pocket  Medical  Dictionary."  Large  octavo,  11 37  pages, 
bound  in  full  flexible  leather.  Price,  ^4.50  net;  with  thumb  index, 
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PATHOLOGY 


Stengel  ^  Fox*s  Pj^thology 

Pathology.  By  Alfred  Stengel,  M.  D.,  Sc.  D.,  Professor  of  Medi- 
cine, University  of  Pennsylvania;  and  Herbert  Fox,  M.  D.,  Director 
of  the  Pepper  Laboratories  of  Clinical  Medicine,  University  of  Pennsyl- 
vania. Octavo  of  1045  pages,  with  468  text-illustrations,  many  in 
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out, reset  in  new  type,  and  a  larger  type  page  used.  New  matter  equivalent  to 
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The  work  is  a  handsome  volume  of  over  1000  pages.  In  the  first  portions,  de- 
voted to  general  pathology,  the  sections  on  inflammation,  retrogressive  processes, 
disorders  of  nutrition  and  metabolism,  general  etiology,  and  diseases  due  to  bac- 
teria were  wholly  rewritten  or  very  largely  recast.  A  new  section  on  transmissible 
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Stiles  on  the  Nervous  System 

The  Nervous  System  and  its  Conservation.  By  Percy  G. 
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Stiles'  Nutritional  Physiology 

Nutritional  Physiology.  By  Percy  Goldthwait  Stiles,  In- 
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ILLUSTRATED 

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"  It  is  remarkable  for  the  fineness  of  its  diction  and  for  its  clear  presentation  of  the  sub- 
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ful." — Colin  C.  Stewart,  Ph.  D.,  Dartmouth  College. 


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Jordan's 
General   Bacteriology 

A  Text=Book  of  General  Bacteriology.  By  Edwin  O.  Jordan,  Ph.D., 
Professor  of  Bacteriology  in  the  University  of  Chicago  and  in  Rush 
Medical  College.     Octavo  of  650  pages,  illustrated.     Cloth,  ;^3.oo  net. 

NEW  (4th)  EDITION 

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pathogenic as  well  as  the  pathogenic  bacteria  being  considered,  giving  greater 
emphasis,  of  course,  to  the  latter.  There  are  extensive  chapters  on  methods  of 
studying  bacteria,  including  staining,  biochemical  tests,  cultures,  etc. ;  on  the 
development  and  composition  of  bacteria  ;  on  enzymes  and  fermentation-products; 
on  the  bacterial  production  of  pigment,  acid  and  alkah  ;  and  on  ptomains  and 
toxins.  Especially  complete  is  the  presentation  of  the  serum  treatment  of  gonor- 
rhea, diphtheria,  dysentery,  and  tetanus.  The  relation  of  bovine  to  human 
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This  work  will  also  appeal  to  academic  and  scientific  students.  It  contains 
chapters  on  the  bacteriology  of  plants,  milk  and  milk-products,  air,  agriculture, 
water,  food  preservatives,  the  processes  of  leather  tanning,  tobacco  curing,  and 
vinegar  making  ;  the  relation  of  bacteriology  to  household  administration  and  to 
sanitary  engineering,  etc. 

Prof.  Severance  Burrage,  Associate  Professor  of  Sanitary  Science ,  Purdue  University. 

"  I  am  much  impressed  with  the  completeness  and  accuracy  of  the  book.  It  certainly 
covers  the  ground  more  completely  than  any  other  American  book  that  I  have  seen. 


Buchanan's 
Veterinary   Bacteriology 

Veterinary  Bacteriology.     By  Robert  E.  Buchanan,  Ph.D.,  Pro- 
fessor of  Bacteriology  in  the  Iowa  State  College  of  Agriculture   and 
Mechanic  Arts.     Octavo,  5 16  pages,  2 14  illustrations.     Cloth,  ^3.00  net. 
THE  BEST  PUBLISHED 

Professor  Buchanan  discusses  thoroughly  all  bacteria  causing  diseases  of  the 
domesdc  animals.  He  goes  minutely  into  the  consideration  of  immunity,  opsonic 
index,  reproduction,  sterilization,  antiseptics,  biochemic  tests,  culture-media, 
isolation  of  cultures,  the  manufacture  of  the  various  toxins,  antitoxins,  tubercuHns, 
and  vaccines  that  have  proved  of  diagnostic  or  therapeutic  value.  Then,  in  addi- 
tion to  bacteria  and  protozoa  proper,  he  considers  molds,  mildews,  smuts,  rusts, 
toadstools,  puff-balls,  and  the  other  fungi  pathogenic  for  animals. 
B.  F.  Kaupp,  D.  V.  S.,  State   Agricultural  College,  Fort  Collins. 

"  It  is  the  best  in  print  on  the  subject.     What  pleases  me  most  is  that  it  contains  all  the  late 
results  of  research.     It  fills  a  long  felt  want." 


EMBRYOLOGY. 


Heisler*s  Embryology 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Pro- 
fessor of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia. 
Octavo  volume  of  435  pages,  with  212  illustrations,  32  of  them  in 
colors.     Cloth,  ^3.00  net. 

THIRD  EDITION— WITH  212  ILLUSTRATIONS,  32  IN  COLORS 

This  edition  represents  all  the  advances  recently  made  in  the  science  of  em- 
bryology. Many  portions  have  been  entirely  rewritten,  and  a  great  deal  of  new 
and  important  matter  added.  A  number  of  new  illustrations  have  also  been  intro- 
duced and  these  will  prove  very  valuable.  Heisler' s  Embryology  has  become 
a  standard  work. 

G.  Carl  Huber.  M.  D., 

Professor  of  Embryology  at  the  Wistar  Institute,  University  of  Pennsylania. 
"  I  find  this  edition  of    'A  Text-Book  of  Embryology,"  by  Dr.  Heisler,  an  improvement 
on  the  former  one.     The  figures  added  increase  greatly  the  value  of  the  work.     I   am  again 
recommending  it  to  our  students." 

Bohm,   Davidoff»  and 
Huber's   Histology 

A  Text=Book  of  Human  Histology.  Including  Microscopic  Tech- 
nic.  By  Dr.  A.  A.  Bohm  and  Dr.  M.  Von  Davidoff,  of  Munich,  and 
G.  Carl  Huber,  M.  D.,  Professor  of  Embryology  at  the  Wistar  Insti- 
tute, University  of  Pennsylvania.  Handsome  octavo  of  528  pages,  with 
361  beautiful  original  illustrations.     Flexible  cloth,  ^3.50  net. 

SECOND  EDITION.  ENLARGED 

The  work  of  Drs.  Bohm  and  Davidoff  is  well  known  in  the  German  edition, 
and  has  been  considered  one  of  the  most  practically  useful  books  on  the  subject 
of  Human  Histology.  This  second  edition  has  been  in  great  part  rewritten  and 
very  much  enlarged  by  Dr.  Huber,  who  has  also  added  over  one  hundred  original 
illustrations.  Dr.  Huber's  extensive  additions  have  rendered  the  work  the  most 
complete  students'  text-book  on  Histology  in  existence. 

Boston  Medical  and  Surgical  Journal 

"  Is  unquestionablv  a  lext-book  of  the  first  rank,  having  been  carefully  written  by  thorough 
masters  of  the  subject,  and  in  certain  directions  it  is  much  superior  to  any  other  histological 
manual." 


lo  SAUXDERS'    BOOKS   ON 

Wells*  Chemical  Pathology 


Chemical  Pathology. — Being  a  Discussion  of  General  Pathology 
from  the  Standpoint  of  the  Chemical  Processes  Involved.  By  H. 
Gideon  Wells,  Ph.  D.,  M.  D.,  Assistant  Professor  of  Pathology  in  the 
University  of  Chicago.     Octavo  of  6i6  pages.      Cloth,  $'^.2^  net. 

NEW  (2d)  EDITION 

Dr.  Wells'  work  is  written  for  the  physician,  for  those  engaged  in  research  in 
pathology  and  physiologic  chemistry,  and  for  the  medical  student.  In  the  intro- 
ductorj'  chapter  are  discussed  the  chemistry-  and  physics  of  the  animal  cell,  giving 
the  essential  facts  of  ionization,  diffusion,  osmotic  pressure,  etc.,  and  the  relation 
of  these  facts  to  cellular  activities.  Special  chapters  are  devoted  to  Diabetes  and 
to  Uric-acid  Metabolism  and  Gout. 

Wm.   H.  Welch.  M.  D. 

Professor  of  Pathology,  Johns  Hopkins  University. 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  ver\'  important  subject,  and  I 
shall  be  glad  to  recommend  it  to  my    students." 

Lusk*s 
Elements  of  Nutrition 

Elements  of  the  Science  of  Nutrition.  By  Graham  Lusk,  Ph.  D., 
Professor  of  Physiology  at  Cornell  Medical  School.  Octavo  volume 
of  302  pages.     Cloth,  ^3.00  net. 

THE  NEW  (2d)  EDITION— TRANSLATED  INTO  GERMAN 

Prof.  Lusk  presents  the  scientific  foundations  upon  which  rests  our  knowledge 
of  nutrition  and  metabolism,  both  in  health  and  in  disease.  There  are  special 
chapters  on  the  metabolism  of  diabetes  and  fever,  and  on  purin  metabolism. 
The  work  will  also  prove  valuable  to  students  of  animal  dietetics  at  agricultural 
stations. 

Lewellys  F.  Barker,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University. 

"  I  shall  recommend  it  highly  to  my  students.  It  is  a  comfort  to  have  such  a  discussion 
of  the  subject  in  English." 


HISTOLOGY.  u 


Daugherty's 
Economic   Zoology 

Economic  Zoology.  By  L.  S.  Daugherty,  M.  S.,  Ph.  D.,  Professor 
of  Zoology,  State  Normal  School,  Kirksville,  l\Io.,  and  ^I.  C.  Daugh- 
erty, author  with  Jackson  of  "  Agriculture  Through  the  Laboratory 
and  School  Garden."  Part  I:  Field  a7id  Laboratory  Guide,  i2mo  of 
237  pages,  interleaved.  Cloth,  $1.25  net.  Part  II:  Principles.  i2mo 
of  406  pages,  illustrated.     Cloth,  $2.00  net. 

ILLUSTRATED 


There  is  no  other  book  just  like  this.  Xot  only  does  it  give  the  salient  facts 
of  structural  zoolog}-  and  the  development  of  the  various  branches  of  animals,  but 
also  the  natural  histor}- — the  life  and  habits — thus  shomng  the  interrelations  of 
structure,  habit,  and  environment.  In  a  word,  it  gives  the  principles  of  zoolog}' 
and  their  actual  application.  The  economic  phase  is  emphasized. 
Part  I — the  Field  and  Laboratory  Guide — is  designed  for  practical  instruction  in 
the  field  and  laboratorj'.  To  enhance  its  value  for  this  purpose  blank  pages  are 
inserted  for  notes. 


DrewV 
Invertebrate  Zoolog'y 

A  Laboratory  Manual  of  Invertebrate  Zoology.  Bv  Gilmax  A. 
Drew,  Ph.D.,  Assistant  Director  at  Marine  Biological  Laborator\^,  Woods 
Hole,  !Mass.  With  the  aid  of  Former  and  Present  ^Members  of  the  Zoological 
Staff  of  Instructors.      i2mo  of  213  pages.  Cloth,  51-25  net. 

NEW    2d  I   EDITION 

The  subject  is  presented  in  a  logical  way,  and  the  type  method  of  study  has 
been  followed,  as  this  method  has  been  the  prevaiUng  one  for  many  years. 

Prof.  Allison  A.  Smyth,  Jr.,  Virginia  Polytechnic  Institute 

"  I  think  it  is  the  best  laboratorv-  manual  of  zooiogT.-  I  have  yet  seen.  The  large  number 
of  forms  dealt  with  makes  the  work  applicable  to  almost  any  locality." 


SAUNDERS'    BOOKS    ON 


Norris*   Cardiac   Patholog(y 

studies  in  Cardiac  Pathology.  By  George  W.  Norris,  M.D. 
Associate  in  Medicine  at  the  University  of  Pennsylvania.  Large  octavo 
of  235  pages,  with  85  superb  illustrations.     Cloth,  ^5.00  net. 

SUPERB    ILLUSTRATIONS 

The  illustrations  are  superb.      Each  illustration  is  accompanied  by  a  detailed 
description;  besides,  there  is  ample  letter  press  supplementing  the  pictures. 

Boston  Medical  and  Surgical  Journal 

"  The  illustrations  are  arranged  in  such  a  way  as  to  illustrate  all  the  common  and  many  of 
the  rare  cardiac  lesions,  and  the  accompanying  descriptive  text  constitutes  a  fairly  continuous 
didactic  treatise." 


McConnelFs  Pathology 

A  Manual  of  Pathology.  By  Guthrie  McConnell,  M.  D.,  As- 
sistant Surgeon,  Medical  Reserve  Corps,  U.  S.  Navy.  i2mo  of  523 
pages,  with  170  illustrations.     Flexible  leather,  ^2.50  net. 

NEW  (2d)  EDITION 
Dr.  McConnell  has   discussed  his  subject  with  a  clearness  and  precision  of 
style  that  make  the  work  of  great  assistance  to  both  student  and  practitioner. 
The  illustrations  have  been  introduced  for  their  practical  value. 

New  York  State  Journal  of  Medicine 

"  The  book  treats  the  subject  of  pathology  with  a  thoroughness  lacking  in  many  works  of 
greater  pretension.  The  illustrations — many  of  them  original — are  profuse  and  of  exceptional 
excellence." 


McConneirs  Pathology  and  Bacteriology  ^%tuAe^. 

Pathology  and  Bacteriology  for  Dental  Students,  By  Guthrie 
McConnell,  M.  D.,  Assistant  Surgeon,  Medical  Reserve  Corps,  U.  S.  N. 
i2mo  of  309  pages,  illustrated.      Cloth,  ^2.25  net. 

ILLUSTRATED 

This  work  is  written  expressly  for  dentists  and  dental  students,  emphasizing 
throughout  the  application  of  pathology  and  bacteriology  in  dental  study  and  prac- 
tice. There  are  chapters  on  disorders  of  metabolism  and  circulation;  retro- 
gressive processes,  cell  division  inflammation  and  regeneration,  granulomas,  pro- 
gressive processes,  tum.ors,  special  mouth  pathology,  sterilization  and  disinfection, 
bacteriologic  methods,  specific  micro-organisms,  infection  and  immunity,  and 
laboratory  technic. 


HISTOLOGY. 


13 


Dtirck  and  Hektoen*s 

Special    Patholog(ic   Histology 

Atlas  and  Epitome  of  Special  Pathologic  Histology.     Bv  Dr.  H. 

DiJRCK,  of  Munich.  Edited,  with  additions,  by  Ludvig  Hektoen,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  two  parts. 
Part  I. — Circulatory,  Respiratory,  and  Gastro-intestinal  Tracts.  120 
colored  figures  on  62  plates,  and  158  pages  of  text.  Part  II. — Liver, 
Urinary  and  Sexual  Organs,  Nervous  System,  Skin,  Muscles,  and 
Bones.  123  colored  figures  on  60  plates,  and  192  pages  of  text.  Per 
part :   Cloth,  ;^3.oo  net.     hi  Saiindei^s'  Hand-Atlas  Series. 

The  great  value  of  these  plates  is  that  they  represent  in  the  exact  colors  the  effect 
of  the  stains,  which  is  of  such  great  importance  for  the  differentiation  of  tissue. 
The  text  portion  of  the  book  is  admirable,  and,  while  brief,  it  is  entirely  satisfac- 
tory in  that  the  leading  facts  are  stated,  and  so  stated  that  the  reader  feels  he  has 
grasped  the  subject  extensively. 

William  H.  Welch.  M.  D., 

Professor  of  Pathology,  Johns  Hopkins  University ,  Baltimore. 

"  I  consider  Diirck's  'Atlas  of  Special  Pathologic  Histology,'  edited  by  Hektoen,  a  very 
useful  book  for  students  and  others.     The  plates  are  admirable." 

Sobotta  am)  Huberts 
Human  Histolog(y 

Atlas  and  Epitome  of  Human  Histology.  By  Privatdocent  Dr. 
J.  Sobotta,  of  Wiirzburg.  Edited,  with  additions,  by  G.  Carl  Huber, 
M.  D.,  Professor  of  Histology  and  Embryology  in  the  University  of 
Michigan,  Ann  Arbor.  With  214  colored  figures  on  80  plates,  6Z 
text-illustrations,  and  248  pages  of  text.  Cloth,  ^4.50  net.  In 
Saimders'  Hand- Atlas  Series. 

INCLUDING   MICROSCOPIC  ANATOMY 

The  work  combines  an  abundance  of  well-chosen  and  most  accurate  illustra- 
tions, with  a  concise  text,  and  in  such  a  manner  as  to  make  it  both  atlas  and  text- 
book. The  great  majority  of  the  illustrations  were  made  from  sections  prepared 
from  human  tissues,  and  always  from  fresh  and  in  every  respect  normal  specimens. 
The  colored  lithographic  plates  have  been  produced  with  the  aidof  over  thirty  colors. 

Boston  Medical  and  Surgical  Journal 

"  In  color  and  proportion  they  are  characterized  by  gratifying  accuracy  and  lithographic 
beauty." 


14  SAUNDERS'    BOOKS   ON 

Bosanquet  on  Spirochaetes 

Spirochastes :  A  Review  of  Recent  Work,  with  Some  Original  Ob- 
servations. By  W.  Cecil  Bosanquet,  M.D.,  Fellow  of  the  Royal  Col- 
lege of  Physicians,  London.    Octavo  of  152  pages,  illustrated,  ;^2.50  net. 

ILLUSTRATED 

This  is  a  complete  and  authoritative  monograph  on  the  spirochaetes,  giving 
morphology',  pathogenesis,  classification,  staining,  etc.  Pseudospirochsetes  are 
also  considered,  and  the  entire  text  well  illustrated.  The  high  standing  of  Dr. 
Bosanquet  in  this  field  of  study  makes  this  new  work  particularly  valuable. 


Levy  an^  Klemperer*s 
Clinical  Bacteriology 

The  Elements  of  Clinical  Bacteriology.  By  Drs.  Ernst  Levy  and 
Felix  Klemperer,  of  the  University  of  Strasburg.  Translated  and 
edited  by  Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine, 
Philadelphia  Polyclinic.  Octavo  volume  of  440  pages,  fully  illustrated. 
Cloth,  ^2.50  net. 

S.  Solis-Cohen,  M.  D., 

Professor  of  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 

"  I  consider  it  an  excellent  book.     I  have  recommended  it  in  speaking  to  my  students." 


Lehmann,  Neumann,  anb 
Weaver's  Bacteriology 

Atlas  and  Epitome  of  Bacteriology :  including  a  Text-Book  of 
Special  Bacteriologic  Diagnosis.  By  Prof.  Dr.  K.  B.  Lehmann 
and  Dr.  R.  O.  Neumann,  of  Wiirzburg.  From  the  Second  Revised  and 
Eiilm^ged  German  Edition.  Edited,  with  additions,  by  G.  H.  Weaver, 
M.  D.,  Assistant  Professor  of  Pathology  and  Bacteriology,  Rush  Medical 
College,  Chicago.  In  two  parts.  Part  I. — 632  colored  figures  on  69 
lithographic  plates.  Part  II. — 511  pages  of  text,  illustrated.  Per  part: 
Cloth,  ;^2.50  net.     In  Saunders'  Hand-Atlas  Series. 


PATHOLOGY,  BACTERIOLOGY,  AND   PATHOLOGY 


IS 


Durck  and  Hektoen*s  General  Pathologic  Histology 

Atlas  and  Epitome  of  General  Pathologic  Histology.  By  Pr. 
Dr.  H.  Durck,  of  Munich.  Edited,  with  additions,  by  Ludvig  Hek- 
TOEN,M.  D.,  Professor  of  Pathology  in  Rush  Medical  College,  Chicago. 
172  colored  figures  on  77  lithographic  plates,  ^6  text-cuts,  many 
in  colors,  and  353  pages.  Cloth,  ^5. 00  net.  In  Saunders' Hand- Atlas 
Series. 

American  Text-Book  of  Physiology  second  Edition 

American  Text-Book  of  Physiology.  In  two  volumes.  Edited  by 
William  H.  Howell,  Ph.  D.  ,  M.  D.  ,  Professor  of  Physiology  in  the  Johns 
Hopkins  University,  Baltimore,  Md.  Two  royal  octavos  of  about  600 
pages  each,  illustrated.  Per  volume:  Cloth,  ^3.00  net;  Half  Morocco, 
M.25  net. 

'•The  work  will  stand  as  a  work  of  reference  on  physiology.  To  him  who  desires  to  know 
the  status  of  modern  physiology,  who  expects  to  obtain  suggestions  as  to  further  physio- 
logic inquiry,  we  know  of  none  in  English  which  so  eminently  meets  such  a  demand  "— 
The  Medical  News, 

Warren's   Pathology  and  Therapeutics        second  Edition 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Med- 
ical School.  Octavo,  873  pages,  136  relief  and  lithographic  illustrations, 
33  in  colors.  With  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis 
and  a  series  of  articles  on  Regional  Bacteriology.  Cloth,  ^5.00  net; 
Half  Morocco,  ^6.50  net. 

Raymond's  Physiology  New  (3d)  Edition 

Human  Physiology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D.,  Pro- 
fessor of  Physiology  and  Hygiene,  Long  Island  College  Hospital,  New 
York.     Octavo  of  685  pages,  with  444  illustrations.     Cloth,  ^3.50  net. 

"  The  book  is  well  gotten  up  and  well  printed,  and  may  be  regarded  as  a  trustworthy 
guide  for  the  student  and  a  useful  work  of  reference  for  the  genera;  practitioner.  The 
illustrations  are  numerous  and  are  well  executed." — The  Lancet,  London. 


l6  BACTERIOLOGY,    PHYSIOLOGY,    AND   HISTOLOGY. 

Ball's    Bacteriology  seventh  Edition,  Revised 

Essentials  of  Bacteriology  :  being  a  concise  and  systematic  intro- 
duction to  the  Study  of  Micro-organisms.  By  M.  V.  Ball,  M.  D.,  Late 
Bacteriologist  to  St.  Agnes'  Hospital,  Philadelphia.  i2mo  of  289  pages, 
with  135  illustrations,  some  in  colors.  Cloth,  ^i.oo  net.  In  Saunders' 
Question-  Conipend  Series. 

"  The  technic  with  regard  to  media,  staining,  mounting,  and  the  lil^e  is  culled  from  the 
latest  authoritative  works." — T/ie  Medical  Times,  New  York. 

Budgett*S    Physiology  New  (3d)  Edition 

Essentials  of  Physiology.  Prepared  especially  for  Students  of  Medi- 
cine, and  arranged  with  questions  following  each  chapter.  By  Sidney 
P.  Budgett,  M.  D.,  formerly  Professor  of  Physiology,  Washington  Uni- 
versit)',  St.  Louis.  Revised  by  Havan  Emerson,  M.  D.,  Demonstratoi 
of  Physiology,  Columbia  University.  i2mo  volume  of  250  pages,  illus- 
trated.    Cloth,  ^ 1. 00  net.     Saunders''  Question- Coinpend  Series. 

"He  has  an  excellent  conception  of  his  subject.  .  .  It  is  one  of  the  most  satisfactory 
books  of  this  class" — University  of  Pennsylvania  Medical  Bulletin. 

Leroy*s  Histology  New  (4th)  Edition 

Essentials  of  Histology.  By  Louis  Leroy,  M.  D.,  Professor  of 
Histology  and  Pathology,  Vanderbilt  University,  Nashville,  Tennessee. 
i2mo,  263  pages,  with  92  original  illustrations.  Cloth,  ^i.oo  net.  In 
Saunders''  Question-  Compend  Series. 

"  The  work  in  its  present  form  stands  as  a  model  of  what  a  student's  aid  should  be  ;  and 
we  unhesitatingly  say  that  the  practitioner  as  well  would  find  a  glance  through  the  book 
of  lasting  benefit." — The  Medical  World,  Philadelphia. 

Barton  and  Wells'  Medical  Thesaurus 

A  Thesaurus  of  Medical  Words  and  Phrases.  By  Wilfred  M. 
Barton,  M.  D.  ,  Assistant  Professor  of  Materia  Medica  and  Therapeutics, 
and  Walter  A.  Wells,  M.D.,  Demonstrator  of  Laryngology,  Georgetown 
University,  Washington,  D.  C.  i2mo,  534  pages.  Flexible  leather, 
I2.50  net;  thumb  indexed,  $3.00  net. 

American  Pocket  Medical  Dictionary       ^ew  (9th)  Edition 

American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  New- 
man Dorland,  M.  D.,  Editor  "American  Illustrated  Medical  Dic- 
tionary." Containing  the  pronunciation  and  definition  of  the  principal 
words  used  in  medicine  and  kindred  sciences,  with  75  extensive  tables. 
693  pages.  Flexible  leather,  with  gold  edges,  $1.00  net;  with  patent 
thumb  index,  $1.25  net. 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  of 
the  Jefferson  Medical  College,  Philadelphia. 


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